AMINO PCC EAMSC 2020: India by AMSA-Indonesia

AMINO | PCC EAMSC 2020: INDIA

The EAMSC 2020 oral presentation videos can be accessed through: bit.ly/OralPresentationEAMSC2020

AMINO | PCC EAMSC 2020: INDIA

FOREWORD

Christina Wunardi Secretary of Academic AMSA-Indonesia 2019/2020

AMSA National Competition Archive, or AMINO, is an archive of all academic works submitted to AMSA-Indonesia competitions, consisting of Pre-Conference Competition East Asian Medical Students’ Conference (PCC EAMSC), Indonesian Medical Students’ Training and Competition (IMSTC) and Pre-Conference Competition Asian Medical Students’ Conference (PCC AMSC). AMINO aims to provide a thorough overview of AMSA-Indonesia’s national competitions to all members of AMSA-Indonesia. On the first volume of AMINO, all the works of PCC EAMSC 2020: India have been compiled and are expected to draw forth inspirations and motivation in creating academic works, including Scientific Paper, Scientific Poster, Public Poster, and Clinical Case Presentation. I would like to thank and express my sincere appreciation to all the participants of PCC EAMSC 2020: India, the Academic Team and Executive Boards of AMSAIndonesia 2019/2020, and other parties that have contributed to the creation of this AMINO. Hopefully, the release of AMINO for PCC EAMSC 2020: India can enhance and intensify the academic enthusiasm and interest of all members of AMSA-Indonesia. “Enhancing Collaboration, Influencing Community” Viva AMSA!

AMINO | PCC EAMSC 2020: INDIA

TESTIMONY

AMINO | PCC EAMSC 2020: INDIA

Ghea Mangkuliguna Scientific Paper

Experience at AMSA AMSA is the very first organization that I joined since entering medical school. AMSA has given me a lot of chances, new experiences. Like they said, it is a ‘complete package’. AMSA has given me courage and opportunity to step my foot to a bigger world. AMSA has been my home and will forever be a home for me. Reasons to Join PCC EAMSC 2020 For sure, experience is what matters. It doesn’t matter if I win or lose, but I just want to give it a go, applicating what I have just learnt these past few months. The paper I have made in this competition is another steppingstone for me. Finally - I think this goes for everyone, as well - the winners of PCC will have the right to represent Indonesia at the international conference. To sum it up, it is another way to be able to attend the conference. Tips and tricks I think diligence, perseverance, and commitment. Those 3 words are the important thing to be remembered when joining a competition. Experience I have always thought this competition is very cool, but I don’t have a single clue on how to make a good paper back then. Recently, I undergo a short training to make a good paper, and I want to try taking a shot. And PCC EAMSC is coincidentally open for paper submission, so I think “why don’t we give it a go?” Sure, making a paper is very time consuming, but the process is what important, I think every second of making the paper is a great experience for me.

AMINO | PCC EAMSC 2020: INDIA

Ekida Rehan Firmansyah Scientific Poster

I am motivated to join AMSA because Iâ&#x20AC;&#x2122;d like to get to know more people both in my university and outside my university. Based on what I have experienced until now as a member of AMSA-UI, I get to know many more people who also join AMSA. I also went to two national events before and I really got to make relations with many more medical faculty students all over Indonesia. As a medical student, I feel that it is very important to learn how to interact nicely with other people including new friends and the society. From AMSA, I also got to meet people who are really underprivileged and Iâ&#x20AC;&#x2122;m grateful to be able to help them in some ways. The most significant benefit that I got beside the things I have mentioned above is how I am able to participate in a lot of academic competition. These experiences taught me a lot of things such as how to make a good literature review, systematic review, poster, and many other kinds of academic competition. To win the competition, you need to learn many new knowledges, look for help by asking the people who have won the competition, and the most important things is the eagerness to learn new things. The only thing that motivates us to join this competition is to look for a new experience and knowledge. The first thing we did was try to see the previous poster from last yearâ&#x20AC;&#x2122;s competition.

AMINO | PCC EAMSC 2020: INDIA

Dandy Bachtiar Hidayat Public Poster

Experience at AMSA AMSA itself is a suitable association for me in developing academic abilities and especially in socializing among its members. So far, AMSA has always provided an opportunity for its members to develop their ability to socialize and also excel through AMSA competitions. Reasons to Join PCC EAMSC 2020 Initially my reason was, so that AMSA Jember could become Champion at PCC EAMSC This Year. But behind that I also have a reason to introduce Emergency Medicine in particular “Handling in handling CAN Snakes that are still not widely known by the public” Benefits of taking part in PCC EAMSC 2020: I discovered something new that I didn’t know about emergency medicine and can boast AMSA Jember among other AMSA universities. Tips and tricks By understanding the problems that are around us, later it will be very interesting for us to discuss / we raise in the title of the race that we will follow. For example: because in my area is an agricultural and plantation area, where there will be many people and animals who depend on nature. The risk of work accidents such as snake bites is inevitable, so there is a need to increase insight into primary and secondary prevention before the problem results in death. Experience This is my third time participating in the Poster Public Contest. so that by participating in competitions often we can learn what innovations I need to improve in order to win in existing competitions

AMINO | PCC EAMSC 2020: INDIA

Yehuda Tri Nugroho Supranoto Clinical Case Presentation

In my opinion, AMSA is an organization that provides many benefits for each member, especially in terms of improving academic quality, social awareness, and of course connections between medical students both nationally and internationally. I have been exposed to the benefits of AMSA since 2017 until now. One of the great benefits I felt was being able to take part in various competitions at AMSA such as the Pre Conference Competition (PCC) East-Asian Medical Students’ Conference (EAMSC). By participating in competitions like the PCC EAMSC, I think we are able to explore further our ability to write, especially in English. Indeed, sometimes it is difficult to start writing, but believe that when you start writing, it’s too bad to stop. For friends who are just starting or are undergoing the pre-clinical phase, let’s start immediately to write and take part in competitions and encourage themselves to have a competitive spirit early on. There is nothing wasted in starting something positive! It’s time for you to start something new and trust the magic of beginning! Goodluck! Viva AMSA!

AMINO | PCC EAMSC 2020: INDIA

TABLE OF CONTENTS SCIENTIFIC PAPER……………………………………………………………1 1st Winner The Potential of N-Myc Downstream-Regulated Gene 2 (NDRG2) as a Novel Diagnostic Biomarker for Colorectal Cancer: A Systematic Review and Meta-analysis..................... 3 2nd Winner Modifiable Survival Factors of Out-of-hospital Cardiac Arrest among Global Population: Systematic Review and Meta-Analysis of Large Cohort Trials........................................... 26 3rd Winner KETAMINE Versus MIDAZOLAM as immediate Management In Acute Suicidal State: A Systematic Review and Meta-Analysis................................................................................. 35 Interleukin-6 For Diagnosis of Neonatal Sepsis: A Systematic Review......... 44 Evaluating Guidelines for Treating Coronary Heart Disease in Hospital Emergency Room: A Systematic Review.............................................................................................. 59 Suicidal Ideation as a Risk Factor of Suicide in Asian Countries for Psychiatric Emergency Screening: A Systematic Review and Meta-Analysis of Case Control Studies................. 74 Cervical Spinal Cord Injury Emergency Treatment Comparison between Developed and Developing Country: A Systematic Review........................................................................... 91 PCC EAMSC INDIA 2020 Emergency Health Care of Refugee: A Systematic Review ............................................................................................................................ 112 Rescue Breathing in Cardiopulmonary Resuscitation: Does It Really Matter? An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trial with Trial Sequence Analysis and Future Insight................................................................................................................. 131 Disaster Medicine: An Urgent Needs for Doctor in Indonesia A Systematic Review ............................................................................................................................ 149 Practice of Interprofessional Education as Health Provider in Emergency of Natural Disaster ............................................................................................................................ 171 More Than Just a Game? The Effectiveness of Virtual Reality Exposure Therapy for Post- Traumatic Stress Disorder (PTSD) in Psychiatric Emergency Setting: A Systematic Review and Meta-analysis ............................................................................................................................ 181

AMINO | PCC EAMSC 2020: INDIA

SCIENTIFIC POSTER……………………………………………………….193 1st Winner Fibrin Sealant as A Topical Hemostatic Agentfor Reducing Postoperative Blood Loss in Orthopedic Surgical Setting: A Systematic Review and Meta-Analysis of Randomized Controlled Trials ............................................................................................................................ 195 2nd Winner Obstetric Emergency Training Approaches to Reduce Maternal Mortality Ratio in Indonesia: A Systematic Review............................................................................................ 197 3rd Winner A New Era: The Use of Technology to Assist Triage in Mass Casualty Incident (MCI) Settings: A Systematic Review ........................................................................................... 200 Potency an Inactivation of PCSK9 Gene to Decrease LDL-C Level Through Genetic Engineering CRISPR / CAS9 as Innovative Efforts toPrevent Coronary Heart Disease: A Systematic Review ............................................................................................................................ 203 Application of Intravenous Artesunate for Severe Imported Malaria Based on WHO Guideline: A Review................................................................................................................ 205 TELEMEDICINE AS A BREAKTHROUGH IN PRE-HOSPITAL MANAGEMENT OF ACUTE CORONARY SYNDROME (ACS) : A SYSTEMATIC REVIEW................................................ 208 KNOWLEDGE ON HYPOGLYCEMIA AMONG PATIENTS WITH DIABETES MELLITUS ............................................................................................................................ 211

AMINO | PCC EAMSC 2020: INDIA

PUBLIC POSTER…………………………………………………………….215 1st Winner AVOID COBRA & DO 3R: Snakebite Emergency Creative Campaign to Reduce Mortality and Morbidity due to Wrong First-Aid Treatment in the Community................. 217 2nd Winner ACUTE DIARRHOEA IN CHILDREN: SIMPLE BUT DEATHABLE................... 219 3rd Winner FIRST AID BURN INJURIES WITH “GET 4C”.................................................. 221 TRAFFIC ACCIDENTS LIFE – SAVING............................................................. 223 SEIZURE More Than 5 Minutes? Be SMART!.................................................. 225 FAST STEPS TO DETECT STROKE................................................................... 227 Ready to ACTION.............................................................................................. 229 BEAT the Stigma, HEAL Your Burn Trauma................................................... 232 SHIELD SOMEONE FROM CHOKING.............................................................. 234 Dealing with Altered or Decreased Levels of Consciousness...................... 236 Snakebite Envenoming: Get to Know the First Aid....................................... 239 Got a snake bite? Do it the R.I.G.H.T way!..................................................... 242 Beat the Bite...................................................................................................... 244 Save Drowning Victim by FLOAT.................................................................... 246 High Five! Five Points to Survive Earthquake................................................ 248 OVERACTIVE OR NOT, YOUR BRAIN IS AMAZING!...................................... 250 Do S.A.F.E for Anaphylaxis............................................................................... 252 When Stroke Strikes Fast, Be Faster Than A Stroke .................................... 254 ALLERGY REACTION HAPPENED?! BE HELPFUL WITH C.A.L.M................ 256 Heat Stroke........................................................................................................ 258 The Relevance of Raising Awareness of ARDS Emergency to Patients’ Chance of Survival............................................................................................................... 260 Adrenal Crisis: Stop Doubting Start Treating.................................................. 262 Is She in GRAVE Danger?................................................................................. 265

AMINO | PCC EAMSC 2020: INDIA LET’S DO “PENTA DON’T” When Epilepsy Seizure Attack Someone......... 268 The Importance of First Aid Awareness......................................................... 270 DROWNING KILLS YOUR FUTURE................................................................. 273 SUDDEN CARDIAC ARREST............................................................................. 275 BEAT The Heat.................................................................................................. 277 BASIC LIFE SUPPORT: A MATTER OF SECONDS.......................................... 280 Be Aware of the Dangers of Hypoglycemia................................................... 282 SEPSIS IS EMERGENCY..................................................................................... 285 CALMING: First-Aid Management of Febrile Seizure in Pediatrics.............. 287 Early Detection and Management of Heart Attack........................................ 289 Seize the Seizure .............................................................................................. 291 Fight Heart Attack with O.R.C.A. Observe – Recognize – Call – Act............ 293 Bring Baby to a Whole New world with MAGIC............................................ 295 “How to Overcome Asthma with STEADY”................................................... 298 SWIM ABC: Guide to First Help in Drowning................................................. 300 See the ALERT, be the expert!......................................................................... 302 Drowning: What to Do and How to Help....................................................... 304 Severe Dehydration.......................................................................................... 306 GIVING PAMPERS FOR INFANT...................................................................... 308 Stroke: Not Just About a Disease, It’s About Quality of Life......................... 310 HUG ME TO SAVE ME....................................................................................... 312 FANTASTIC for Choking................................................................................... 314 The Emergency of Choking............................................................................. 317 112 Only One Call Away................................................................................... 319 DO SAFE TO SAVE A LIVES.............................................................................. 321 Importance of Anaphylactic Shock Awareness............................................. 323 Time is Muscle: Act now before it’s too late.................................................. 325 Heat Stroke Can Kill You! ............................................................................... 327 Alcohol-Like Mouth Odor!? CAUTION!........................................................... 330

AMINO | PCC EAMSC 2020: INDIA

TRIPLE C: FOR BURNS..................................................................................... 332 Management of Snakes Bite............................................................................ 334 The Other Side of Diarrhea.............................................................................. 336 STROKE? ACT FAST AND LIFE WILL LAST.................................................... 339 Save Life from Getting Electric Shock with SMACK...................................... 341 Seizure, Make Sure You’re Not Insecure........................................................ 343 Cardiogenic Pulmonary Edema: Every Breath Counts................................. 345 How to PASS Shortness of Breath................................................................... 348 Watch Your Drugs, As It can Leads to Severe Allergy................................... 351 WHAT TO DO WHEN THE WORLD SHAKES?............................................... 354 WE NEED YOU (ALIVE)!................................................................................... 357 PREVENT SUICIDE WITH SHINE..................................................................... 359 Beware of Eclampsia: Treat with ‘TIC TAC’................................................... 361

AMINO | PCC EAMSC 2020: INDIA

CLINICAL CASE PRESENTATION……………………………………….363 1st Winner A Case Report: Surgical Site Infection of Open Fracture Grade IIIC Caused by Biofilm-Producing Methicillin-Resistant Staphylococcus aureus (MRSA) in RSD dr. Soebandi Jember ............................................................................................................................ 365 2nd Winner A Case Report: Multitrauma After a Single Motorcycle Accident (Intracranial Hemorrhage, Acute Subdural Hematoma, Acute Subdural Hygroma, Closed Fracture Mandible, and Open Fracture Tibia Fibula Grade III A)................................................................................... 377 3rd Winner Grade III hypovolemic shock following antepartum hemorrhage in a patient with placenta previa and placenta accreta spectrum: a clinical case presentation..................... 398 CASE REPORT: UTERINE ATONY AS ONE OF THE POSTPARTUM HEMORRHAGES AND THE PROPOSED USE OF TAMPON

BALLOONS................................................. 415

A CASE REPORT: DIRECT HYPERBILIRUBINEMIA IN 28-YEAR-OLD PATIENT WITH INTRAUTERINE FETAL DEATH.................................................................................................... 427 A Case Report: Status Epilepticus and Loss of Consciousness in a Child with Human Immunodeficiency Virus (HIV) Suffering from Tuberculosis Meningoencephalitis and Cerebral Toxoplasmosis Co-Infection............................................................................ 435

AMINO | PCC EAMSC 2020: INDIA

The Potential of N-Myc Downstream-Regulated Gene 2 (NDRG2) as a Novel Diagnostic Biomarker for Colorectal Cancer: A Systematic Review and Meta-analysis Ghea Mangkuliguna1a, Abigail Tania1, Felicia1, Jenifer Nathania1 1

Undergraduate Medical Program, School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia Asian Medical Students’ Association Indonesia a

mangkuligunaVG1402@yahoo.com

ABSTRACT Introduction: Colorectal cancer (CRC) is the second leading cause of oncological death worldwide. Currently, early screening for precancerous lesions using colonoscopy is recommended to decrease mortality. Another less-invasive method to diagnose CRC is by using tumor marker, but they mostly showed significant results only in predicting patients’ outcome. As a result, more than 60% of CRC cases are not detected in early stage. Moreover, studies suggested that up to 33% of CRC patients are present as an emergency cases with ‘red-flag’ symptoms. At this point, CRC has typically reached the advanced stage where liver metastases are unresectable and 5-year survival rate is lower than 12%. Objective: This systematic review and meta-analysis will investigate the association between the expression level of NDRG2 and CRC, as well as the sensitivity of specificity of NDRG2 in detecting CRC. Materials and Method: This meta-analysis is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Literature search is carried out in electronic databases, such as PubMed, EBSCO, ScienceDirect, Cochrane, and ProQuest. Odds Ratio (OR) with a confidence interval (CI) of 95% will be used to determine the association between NDRG2 promoter methylation or expression level and CRC. Pooled sensitivity and specificity will also be calculated to evaluate the diagnostic perfomance of NDRG2 promoter methylation and expression in distinguishing CRC and normal tissue. Key Findings: Ten studies were included in the meta-analysis. The current study shows that NDRG2 promoter is hypermethylated (OR=13.64, 95% CI: 7.38-25.21, p=0.14, I2=46%) in CRC and NDRG2 expression is significantly reduced (OR = 0.05; 95% CI: 0.030.07; p = 0.13; I2 = 41%) in CRC. The pooled sensitivity and specificity of NDRG2 promoter methylation in detecting CRC are 83% (95% CI: 0.75-0.90) and 86% (95% CI: 0.60-0.96), respectively. Meanwhile, the pooled sensitivity and specificity of NDRG2 expression in detecting CRC are 87% (95% CI: 0.76-0.94) and 76% (95% CI: 0.71-0.81). In addition, SROC analysis showed NDRG2 promoter methylation and NDRG2 expression have very good to excellent diagnostic accuracy. Conclusion: This systematic review and meta-analysis provide evidences suggesting NDRG2 as a potential diagnostic biomarker for colorectal cancer. Keywords: colorectal cancer, diagnostic biomarker, meta-analysis, NDRG2, systematic review

The Potential of N-Myc Downstream-Regulated Gene 2 (NDRG2) as a Novel Diagnostic Biomarker for Colorectal Cancer: A Systematic Review and Meta-analysis

Author: Ghea Mangkuliguna Abigail Tania Felicia Jenifer Nathania

School of Medicine and Health Science Atma Jaya Catholic University of Indonesia Asian Medical Studentsâ&#x20AC;&#x2122; Association Indonesia 2019

typically reached the advanced stage where

Introduction Colorectal cancer (CRC) is defined as

liver metastases are unresectable and 5-year

the formation of malignant cells either in colon

survival rate is no higher than 12% (Amri et al.,

or rectum. CRC is the third most common

2015;

cancer in men and the second most common

chemotherapy and targeted agents can prolong

cancer in women. In 2018, it is reported that 1.8

overall survival up to 2 years long, however,

millions of people worldwide are diagnosed

they can induce potentially life-threatening

with CRC (Favoriti et al., 2016; Marley et al.,

side-effects, such as oxaliplatin-induces severe

2016; Douaiher et al., 2017). According to

anaphylactic shock – a condition requiring

International Agency for Research on Cancer

emergency management (Wang et al., 2012;

(IARC), this number is 2.3 times much higher,

Prenen et al., 2015).

Geng

Currently,

compared with CRC incidence in the previous

al.,

early

2017).

Although

screening

for

year which is only 800.000 new cases in 2012.

precancerous lesions is the most ideal strategy

Not only does the incidence keeps on rising, but

to decrease mortality (Favoriti et al., 2016;

also CRC is the second leading cause of

Singh et al., 2017). However, this approach

oncological death worldwide, with an estimated

yields several drawbacks, such as high

880.000 CRC deaths in 2018 (9.2% of all

invasiveness, high cost, and poor patient

cancer deaths that year).

compliance. A less-invasive method to detect

Patients with CRC will present with

CRC is by using tumor marker. However,

acute conditions during the progression of the

among all of the known biomarkers for CRC

disease and treatment which makes them very

recommended by European Group of Tumor

susceptible to a wide range of medical

Markers (EGTM), none have shown a

emergencies (Barnett et al., 2013). Early

significant value as an early diagnostic marker

symptoms of CRC are often overlooked by

(Duffy et al., 2013). Even the widely used

most medical practitioners until the patients

biomarker for CRC, carcinoembryonic antigen

have shown signs of oncological emergencies,

(CEA) has only been able to predict patients’

e.g. large bowel obstruction and perforation or

outcome, monitor therapy, and follow-up for

even acute lower gastrointestinal bleeding, as a

any possible recurrence (Duffy et al., 2001;

result of local tumor invasion or regional

Duffy et al., 2013; Lech et al., 2016). As a result,

metastases (Barnett el al., 2013; Prenen et al.,

more than 60% of asymptomatic patients are

2015; Amri et al., 2015; Pisano et al., 2018).

very unlikely to be early diagnosed with CRC

Studies suggested that up to 33% of CRC

(Barnett et al., 2013). Developing an effective

patients are present with these ‘red-flag’

early diagnostic tool has become a global

symptoms that required emergency surgery

urgency and must be resolved as soon as

immediately (Hogan et al., 2015; Renzi et al.,

possible for the incidence and mortality rate of

2016; Baer et al., 2017; Esteva et al., 2018;

CRC keep on rising in an alarming state.

Littlechild et al., 2018). At this point, CRC has 2 5

This

Recently, several studies have shown

meta-analysis

reported

that tumorigenesis in CRC is the accumulation

following the Preferred Reporting Items for

of both genetic and epigenetic alterations (Kim

Systematic

et al., 2007; Jia et al., 2013; Ashktorab et al.,

(PRISMA) criteria. The protocol used in this

2014; Zamani et al., 2018). Epigenetic changes,

study has been registered in International

especially aberrant DNA methylation, have

Prospective Register of Systematic Reviews

particularly become a field of interest in

(PROSPERO) (CRD42019132174).

Reviews

and

Meta-Analyses

understanding the progression of CRC itself. It is reported that hypermethylation of CpG

Eligibility Criteria

islands in promoter gene leads to the silencing

The following criteria are considered

of tumor suppressor genes (TSG). Moreover,

for

DNA methylation tends to occur in the early

participants, index test, target condition, and

stage of malignancy which creates a molecular

reference standards.

studiesâ&#x20AC;&#x2122;

eligibility:

type

study,

signature excellent for early detection and prognosis of CRC (Kim et al., 2007; Piepoli et

Type of Studies

al., 2009; Ashktorab et al., 2014). Based on

Cross-sectional, cohort, and case-

these conjectures, researchers have shifted their

control studies are included. Review, case

focus on identifying specific genes in CRC

report, case series, and conference abstracts are

patients that abberantly expressed because of

excluded. Articles with unavailable full-text,

DNA hypermethylation. Among all of the

languages other than English, and irrelevant

genes identified, only N-myc downstream-

topics are also omitted.

regulated gene 2 (NDRG2) has shown significant CpG islands hypermethylation in

Participants

several human colon cancer cell line (Piepoli et

All patients diagnosed with CRC are

al., 2009).

included for this study. Participants from both

This systematic review and metaanalysis

will

investigate

the

clinical and community settings are included.

association

There is no limitation for age, gender, races,

between the expression level of NDRG2 and

and history of treatment.

colorectal cancer. This study will also investigate the sensitivity and specificity of

Index Test

NDRG2 in detecting colorectal cancer.

Studies evaluating NDRG2 promoter methylation

and

expression

Materials and Method

colorectal cancer are included.

Study Registration and Methodology

Target Condition

humansâ&#x20AC;&#x2122;

Studies include all colorectal cancer stage according to TNM system (0/I/II/III/IV) 3 6

Dukes’

stage

(A/B/C)

and

text articles are thoroughly assessed using the

tumor

eligibility criteria described above. Any

differentiation status: well/moderate/poor.

emerging discrepancies will be resolved by consensus among the review team. The planned

Reference Standard

procedure is illustrated in Figure 1.

The reference standard is a clinical examination

performed

qualified Data Extraction

professionals by comparing NDRG2 promoter methylation status and expression in CRC and

The following data is extracted from

normal biopsy tissues with RT-PCR or

the included studies: first author, publication

immunohistochemistry.

year, region, study design, age, gender, race, sample size, clinicopathological data, and

Data Sources and Search

method of genotyping. The number of true-

Literature search is carried out with

positive, true-negative, false-positive, and fase-

multiple electronic databases, such as PubMed,

negative results are also identified to create a

EBSCO,

2x2 table for each study.

ScienceDirect,

Cochrane,

and

ProQuest. No time and language restriction is Quality Assessment

applied. The keywords used are described as follow:

“NDRG2”

Family

Each study are assessed for their

Downstream-

quality by using Quality Assessment of

Regulated Gene 2 Protein” OR “Protein

Diagnostic Accuracy Studies – 2 (QUADAS 2).

NDRG2” OR “SYLD” OR “NDR1-Related

This tool consists of 4 key domains: patient

Protein NDR2” OR “Cytoplasmic Protein Ndr1”

selection, index test, reference standard, and

OR “Syld709613” OR “KIAA1248” AND

flow and timing. Each domain is evaluated for

“colorectal cancer” OR “colorectal tumor” OR

risk of bias, and the first 3 domains are also

“colorectal carcinoma” OR “CRC” OR “rectal

evaluated for concern regarding applicability to

cancer” OR “rectal tumor” OR “rectal

the research question. Any discrepancies will

carcinoma” OR “colon cancer” OR “colon

be resolved by discussion among the review

tumor” OR “colon carcinoma” OR “bowel

team.

Member

2”

“NDRG

“N-Myc

cancer” OR “bowel tumor” OR “bowel carcinoma”.

Data Analysis All statistical tests for this meta-

Study Selection Articles

analysis are done using Review Manager are

identified

using

(RevMan) v5.3 and MetaDTA v1.25.

the

keywords described above. After removing Data Synthesis

duplicates using EndNote program, retrieved articles are screened based on their titles and

Odds Ratio (OR) with a confidence

abstracts. Thereafter, potentially eligible full-

interval (CI) of 95% will be used to determine 4 7

the association between NDRG2 promoter

means there is significant sensitivity and

methylation or NDRG2 expression level and

specificity. Statistical differences in sensitivity

CRC. If OR equal to 1 is included in the

and specificity will be further examined to

calculated CI, it means that there is no

compare the diagnostic perfomance of the

significant association between expression

selected diagnostic tools. Diagnostic data will

level of NDRG2 and CRC or NDRG2 promoter

be presented in forest plot and summary

methylation and CRC. To determine the effect

receiver operating characteristics (sROC) curve.

size, either fixed-effect model (FEM) or

Test accuracy is defined based on the

random-effect model (REM) will be chosen.

corresponding areas under the curve (AUC):

FEM will be used if the included studies are

<0.5 (not useful), 0.5-0.6 (bad), 0.6-0.7

considered homogenous (same design and

(sufficient), 0.7-0.8 (good), 0.8-0.9 (very good),

methodology or low variability in studiesâ&#x20AC;&#x2122;

and 0.9-1.0 (excellent).

results or variation due to random error). Heterogeneity Evaluation

Otherwise, if heterogeneity between included studies is combined, REM will be used. Pooled

Heterogeneity of included studies is

estimate will be presented in forest plot. Pooled

assessed using Cochraneâ&#x20AC;&#x2122;s Q Test (chi-squared)

sensitivity

and Higgins I2 statistics. For the Q statistics, if

calculated. If calculated value is >50%, it

the calculated p-value from chi-squared test is

and

specificity

will

also

5 8

lower than 0.1, included studies will be

included in the meta-analysis at last (Kim et al.,

assumed to have statistical heterogeneity. For I

2009; Piepoli et al., 2009; Shi et al., 2009; Chu

statistics, calculated value less than 25% means

et al., 2011; Feng et al., 2011; Shen et al., 2014;

strong homogeneity, 25-75% is average, more

Xu et al., 2015; Hong et al., 2016; Ma et al.,

than 75% indicates strong heterogeneity.

2017; Yamamura et al., 2017). Search

Subgroup analysis will be performed to find

flowchart and selection methods used this meta-

any possible sources of heterogeneity.

analysis was summarized in Figure 1.

Publication Bias

Characteristics of Included Studies

Publication bias is assessed visually

In 6 studies, NDRG2 expression in

using funnel plot. An asymmetrical shape

CRC and normal tissue was evaluated. NDRG2

indicates the presence of publication bias.

expression based on tumor differentiation status was assessed in 6 studies (Kim et al., 2009; Shi

Results

et al., 2009; Chu et al., 2011; Shen et al., 2014; Xu et al., 2015; Ma et al., 2017) whereas on

Search Results

tumor staging was assessed in 4 studies (Kim et

Search in electronic database yielded

al., 2009; Chu et al., 2011; Shen et al., 2014; Ma

1763 studies. Screening through titles and

et al., 2017). This meta-analysis also evaluated

abstracts found 25 articles, 18 of which met the

NDRG2 promoter methylation status in CRC

inclusion criteria. A total of 10 studies were

and normal colon tissue in 4 studies (Piepoli et

6 9

al., 2009; Feng et al., 2011; Shen et al., 2014;

normal tissues. Pooled analysis revealed that

Hong et al., 2016). Gathered data from 1502

NDRG2 promoter was significanly (p<0.0001)

sample tissues (656 of normal and 846 of CRC

hypermethylated in CRC (Pooled OR = 13.64;

tissues) were pooled and analyzed together.

95% CI: 7.38-25.21; p = 0.14; I2 = 46%).

Characteristics

Finding of this section is presented in Figure 2.

included

studies

are

presented in Table 1.

Publication bias was not observed for this study

Table 2 shows methodological quality

(Figure 3) and no heterogeneity was found.

assessment of included studies according to QUADAS-2. Only 1 study has low risk of

NDRG2 Expression to Detect Colorectal

patient selection for the rest of the studies are

Cancer

using case-control design. Regarding index

Six studies had assessed NDRG2

tests, reference standard, and flow and timing,

expression in distinguishing CRC from normal

all of the included studies have low risk of bias.

tissues. Pooled analysis demonstrated that there is statistically significant (p<0.0001) difference

Meta-analysis

in NDRG2 expression between CRC and normal tissues (Pooled OR = 0.05; 95% CI:

NDRG2 Promoter Methylation to Detect

0.03-0.07; p = 0.13; I2 = 41%). Finding of this

Colorectal Cancer

section is presented in Figure 4. Publication

Four

studies

evaluated

NDRG2

bias was not observed for this study (Figure 5)

promoter methylation to distinguish CRC and

and no heterogeneity was found. 7 10

Six studies further evaluated NDRG2

used as control and staging system were the

expression to detect colorectal cancer based on

sources of heterogeneity, as shown in Table 4.

tumor differentiation status. NDRG2 expression

The use of paired normal tissue as control has

was slighly reduced (p=0.03) in moderately and

shown NDRG2 reduction to a greater extent

poorly differentiated tumors (Pooled OR = 0.38;

(OR = 0.93; 95% CI: 0.41-2.08) compared to

95% CI: 0.26-0.54; p = 0.007; I = 69%)

adjacent (OR = 0.03; 95% CI: 0.00-0.27) or

(Figure

distant (OR = 0.08; 95% CI: 0.02-0.31) normal

6a).

Due

considerable was

tissues as control. Findings also showed

performed. According to the findings presented

considerable reduction in NDRG2 expression

in Table 3, the source of heterogeneity was the

when WHO staging system was used (OR =

tissue model used as control. NDRG2 down-

0.93; 95% CI: 0.41-2.08).

heterogeneity,

subgroup

analysis

regulation was considerably greater when paired normal tissue was used as control (OR =

Comparison of Sensitivity and Specificity

0.71; 95% CI: 0.40-1.26) compared to adjacent

between NDRG2 Promoter Methylation and

normal tissue (OR = 0.09, 95% CI: 0.03-0.27).

NDRG2 Expression in Detecting CRC

NDRG2 expression was also evaluated

Based on the above facts and figures,

based on tumor staging. Five studies revealed

we further investigate the sensitivity and

reduced NDRG2 expression (p=0.02) as tumor

specificity

progressed even further (Pooled OR = 0.42; 95%

methylation and NDRG2 expression (Figure 7).

CI: 0.28-0.64; p = 0.003; I2 = 75%) (Figure 6b).

The pooled sensitivity and specificity of

Subgroup analysis revealed that tissue model

NDRG2 promoter methylation in detecting

both

NDRG2

promoter

8 11

CRC are 83% (95% CI: 0.75-0.90) and 86% (95%

system, immune system and bone marrow, skin,

CI: 0.60-0.96), respectively. Meanwhile, the

respiratory tract, endocrine glands, others

pooled sensitivity and specificity of NDRG2

including cardiac and skeletal muscles, brain

expression in detecting CRC are 87% (95% CI:

astrocytes and oligodendrocytes (Li et al.,

0.76-0.94) and 76% (95% CI: 0.71-0.81). In

2008). Recently, NDRG2 has gained a lot of

addition, SROC analysis showed NDRG2

attention for its role as a tumor-suppressor gene.

promoter methylation and NDRG2 expression

Mediated by various proteins, NDRG2 inhibits

have very good to excellent diagnostic accuracy

tumor proliferation, suppress tumor invasion

(Figure 8). There is no statistically significant

and metastasis, as well as disrupt energy

difference in pooled sensitivity and specificity

metabolism needed for tumor growth (Geleta et

al., 2016; Hu et al., 2015; Hu et al., 2016; Vaes

NDRG2

promoter

methylation

and

et al., 2018).

expression.

Several

vitro

studies

have

demonstrated the association between NDRG2

Discussion NDRG2 is a Myc-repressed gene

promoter methylation or expression and

belonging to N-myc Downstream-regulated

colorectal cancer (Piepoli et al., 2009; Feng et

Gene (NDRG) family. NDRG2 is widely

al., 2011; Golestan et al., 2015; Golestan et al.,

expressed in various human tissues, such as

2017; Hong et al., 2016; Lorentzen &

digestive tract, reproductive system, urinary

Mitchelmore, 2017; Xu et al., 2015). Aberrant 9 12

methylation of CpG islands in the promoter

0.007; I2 = 69%) and advanced tumor stage (OR

region is associated with the down-regulation of

= 0.42; 95% CI: 0.28-0.64; p = 0.003; I2 = 75%).

NDRG2, as seen in most CRC cases. NDRG2

The source of heterogeneity mostly comes from

expression is also regulated by cellular Myc (c-

the tissue model used as control. However, the

Myc), a proto-oncogene served as a master

extent of NDRG2 reduction is more apparent

switch for cell proliferation and differentiation

when paired normal tissue was used as control.

(Li et al., 2008; Piepoli et al., 2009; Feng et al.,

The reason is probably that paired tissue is more

2011; Hong et al., 2016; Yamamura et al.,

representative

2017). c-Myc is overexpressed in humansâ&#x20AC;&#x2122;

diseased region. Finally, we compare the

CRC leading to suppression of NDRG2

sensitivity and specificity of NDRG2 promoter

expression mediated by Miz-1 protein (Shi et al.,

methylation and expression in detecting CRC.

2009; Zhang et al., 2019). Clinical studies have

Both of them exhibit favourable diagnostic

shown that reduced expression of NDRG2 is

perfomance to be able to distinguish patients

linked to poorer tumor differentiation status and

with and without CRC. Detecting CRC with

poorer prognosis (Chu et al., 2011; Feng et al.,

NDRG2

2011; Hong et al., 2016; Kim et al., 2009; Kim

sensitivity (87% vs 83%), while using NDRG2

et al., 2012; Lorentzen et al., 2007; Ma et al.,

promoter

2017; Piepoli et al., 2009; Shen et al., 2014; Shi

specificity (86% vs 76%). Overall, this finding

et al., 2009; Vaes et al., 2018; Yamamura et al.,

is comparable to the perfomance of standard

2017).

CRC

normal-counterpart

expression methylation

diagnostic

has has

tools,

shown shown

such

greater better

fecal

To the best of our knowledge, there is

immunochemical test (FIT) (Benton et al., 2015;

no comprehensive study conducted until now

Rex et al., 2017) and colonoscopy (Lauby-

that evaluate the diagnostic perfomance of

Secretan et al., 2018; Steele et al., 2014;

NDRG2 promoter methylation and expression

Swiderska et al., 2013).

to detect CRC. Consistent with the previous studies, the current meta-analysis shows that

Strengths and Limitations

NDRG2 promoter is heavily hypermethylated

The current study has several strengths.

(OR=13.64, 95% CI: 7.38-25.21, p=0.14,

This is the first systematic review and meta-

I2=46%) in CRC. Another finding is that

analysis generating and comparing the pooled

NDRG2 expression is reduced (OR = 0.05; 95%

sensitivity and specificity of NDRG2 promoter

CI: 0.03-0.07; p = 0.13; I = 41%) in CRC. We

methylation and expression in distinguishing

also further investigated whether there is

CRC and normal tissue. Moreover, the protocol

significant

NDRG2

used in this study has been registered and

expression and tumor differentiation status and

approved by International Prospective Register

tumor stage. NDRG2 expression is significantly

of Systematic Reviews (CRD42019132174).

reduced in moderately and poorly differentiated

Publication bias is not observed as shown in the

tumor (OR = 0.38; 95% CI: 0.26-0.54; p =

symmetrical funnel plot. There is no significant

association

between

10 13

heterogeneity in studies evaluating NDRG2

Further comprehensive studies should

promoter methylation and expression between

be done to investigate the extent of reduced

CRC and normal tissue.

NDRG2 expression in humans’ CRC, as it several

would serve as a foundation for future research

limitations. First, a larger sample size is

in cancer biomarker. Moreover, we recommend

required for the calculated OR from this meta-

more studies done in American, European,

analysis to be representative in worldwide

Australian, and African countries to confirm the

population. Included studies mostly originate in

applicability of this diagnostic tools worldwide.

The

current

study

has

Asia (China, Japan, and Korea), while only 1 study is done in Italy. Second, the limited

References

number of studies with adequate data makes it

Amri, R., Bordeianou, L. G., Sylla, P., & Berger,

difficult to explain the heterogeneity occuring

D. L. (2015). Colon cancer surgery

when NDRG2 expression is evaluated based on

following emergency presentation: Effects

tumor differentiation status or tumor stage.

on admission and stage-adjusted outcomes.

Third, the limited evidence availaible implies

American Journal of Surgery, 209(2), 246–

that this meta-analysis must be interpreted with

253.https://doi.org/10.1016/j.amjsurg.201

caution.

4.07.014 Ashktorab, H., & Brim, H. (2014). DNA

Conclusion This

meta-analysis

revealed

that

Methylation

and

Colorectal

Cancer. Current

colorectal

cancer

NDRG2 expression are reduced to absent in

reports, 10(4),

humans’

doi:10.1007/s11888-014-0245-2

CRC.

the

same

time,

Baer,

hypermethylation of NDRG2 promoter region

C.,

425–430.

Menon,

Bastawrous,

and

tumor

presentations of colorectal cancer. Surg

differentiation/stage and survival rate. The

Clin North Am, 97(3), 529-545. doi:

present study also demonstrates that NDRG2

10.1016/j.suc.2017.01.004

contributes

poorer

(2017).

S.,

is associated with low expression of NDRG2 thus

R.,

Emergency

Barnett, A., Cedar, A., Siddiqui, F., Herzig, D.,

promoter methylation and expression have in

Fowlkes, E., & Thomas, C. R. J. (2013).

distinguishing CRC and normal tissue. Hence,

Colorectal cancer emergencies. Journal of

this systematic review and meta-analysis

Gastrointestinal Cancer, 44(2), 132–142.

provide evidences for the use of NDRG2 as a

https://doi.org/10.1007/s12029-012-9468-

potential diagnostic biomarker for colorectal

favourable

sensitivity

and

specificity

Benton, S. C., Seaman, H. E., Halloran, S. P.

cancer.

(2015). Faecal Occult Blood Testing for Colorectal Cancer Screening: the Past or

Recommendation

the Future. Curr Gastroenterol Rep, 17, 7. 11 14

e0203556.

Chu, D., Zhang, Z., Li, Y., Wu, L., Zhang, J.,

doi:10.1371/journal.pone.0203556

Wang, W., Zhang, J. (2011). Prediction of colorectal cancer relapse and prognosis by

Favoriti, P., Carbone, G., Greco, M., Pirozzi,

tissue mRNA levels of NDRG2. Mol

F., Pirozzi, R.E., Corcione, F. (2016).

Cancer Ther, 10, 47-56.

Worldwide burden of colorectal cancer: a

Colorectal Cancer. (2019). Retrieved 15 September

2019,

review. Updates Surg, 68(1), 7-11. doi:

from

10.1007/s13304-016-0359-y Feng, L., Xie, Y., Zhang, H., Wu, Y. (2011).

https://www.cancer.gov/types/colorectal

Down-regulation

Colorectal Cancer Statistics. (2019). Retrieved 15

September

2019,

NDRG2

gene

expression in human colorectal cancer

from

https://www.wcrf.org/dietandcancer/cance

involves

r-trends/colorectal-cancer-statistics

microRNA-650. Biochem Biophys Res

Douaiher,

J., Ravipati,

promoter

methylation

and

Commun, 406(4), 534-8.

A., Grams,

B., Chowdhury, S., Alatise, O., Are, C.

Freeman, S. C., Kerby, C. R., Patel, A., Cooper,

(2017). Colorectal cancer-global burden,

N. J., Quinn, T., Sutton, A.J. (2019).

trends, and geographical variations. J Surg

Development of an interactive web-based

Oncol,

tool to conduct and interrogate meta-

115(5),

619-630.

doi:

analysis of diagnostic test accuracy studies:

10.1080/14737159.2017.1337511

MetaDTA.

Duffy, M. J. (2001). Carcinoembryonic antigen

BMC

Medical

Research

as a marker for colorectal cancer: Is it

Methodology,

clinically useful? Clinical Chemistry,

https://doi.org/10.1186/s12874-019-0724-

47(4), 624-630.

Duffy, M. J., Lamerz, R., Haglund, C., Nicolini,

19,

81.

Geleta, B., Makonnen, E., Abay, S. M. (2018).

A., Kalousová, M., Holubec, L., &

N-myc

Sturgeon, C. (2014). Tumor markers in

(NDRG): Role in Cancer Metastasis

colorectal cancer, gastric cancer and

Suppression and as Drug Target in Cancer

gastrointestinal stromal cancers: European

Therapeutics. J Cancer Sci Ther, 8, 154-

group on tumor markers 2014 guidelines

159.

update. International

journal

cancer, 134(11),

Downstream

Regulated

Gene

Geng, F., Wang, Z., Yin, H., Yu, J., Cao, B.

2513–2522.

(2017). Molecular targeted drugs and treatment of colorectal cancer: recent

doi:10.1002/ijc.28384 Esteva, M., Ruidíaz, M., Sánchez, M. A.,

progress and future perspectives. Cancer

Pértega, S., Pita-Fernández, S., Macià,

Biotherapy and Radiopharmaceuticals,

F.,

32(5),

…

DECCIRE

GROUP

(2018).

Emergency presentation of colorectal patients

Spain. PloS

149-160.

doi:

10.1089/cbr.2017.2210.

one, 13(10),

GLOBOCAN 2018: estimated cancer incidence, mortality, and prevalence worldwide in 12 15

2018. (2019). Retrieved 13 September

diverse human cancers. Apoptosis, 21(6),

2019, from http://globocan.iarc.fr

675-82. doi: 10.1007/s10495-016-1244-3.

Golestan, A., Ghaderi, A., Mojtahedi, Z. (2017).

Jia, Y., & Guo, M. (2013). Epigenetic changes

Effects of NDRG2 Overexpression on

in colorectal cancer. Chinese journal of

Metastatic

cancer, 32(1),

Behaviors

HCT116

Colorectal Cancer Cell Line. Adv Pharm

21–30.

doi:10.5732/cjc.011.10245

Bull, 7(4), 661–664.

Kim, A., Kim, M. J., Yang, Y., Kim, J. W.,

Golestan, A., Mojtahedi, Z., Ghalamfarsa, G.,

Yeom, Y. I., Lim, J. S. (2009). Suppression

Hamidinia, M., Takhshid, M. A. (2015).

The Effects of NDRG2 Overexpression on

expression attenuates the invasive potential

Cell Proliferation and Invasiveness of

SW48 Colorectal Cancer Cell Line. Iran J

Carcinogenesis, 30, 927-936.

Med Sci, 40(5), 430–439.

NF-kappaB highly

activity

malignant

NDRG2

tumor

cells.

Kim, J. T., Kim, J. W., Kang, Y. H., Kim, K.

Hogan, J., Samaha, G., Burke, J., Chang, K. H.,

D., Lee, S. J., Choi, S. C., … Lee, H. G.

Condon, E., Waldron, D., Coffey, J. C.

(2012). NDRG2 and PRA1 interact and

(2015). Emergency Presenting Colon

synergistically inhibit T-cell factor/β-

Cancer Is an Independent Predictor of

catenin signaling. FEBS Lett, 586(22),

Adverse Disease-Free Survival. Int Surg,

3962-8. doi: 10.1016/j.febslet.2012.09.045.

100(1),

77-86.

Kim, Y. J., Kang, H. B., Yim, H. S., Kim, J. H.,

https://doi.org/10.9738/INTSURG-D-13-

Kim, J. W. (2013). NDRG2 positively

00281.1

regulates

Hong, S. N., Kim, S. J., Kim, E. R., Chang, D.

E-cadherin

expression

and

prolongs overall survival in colon cancer

K., Kim, Y. H. (2016). Epigenetic

patients. Oncol Rep, 30, 1890-1898.

silencing of NDRG2 promotes colorectal

Kim, Y. J., Yoon, S. Y., Kim, J. T., Choi, S. C.,

cancer proliferation and invasion. Journal

Lim, J. S., Kim, J. H., … Kim, J. W. (2009).

of Gastroenterology and Hepatology, 31,

NDRG2

164– 171.

through down-regulation of AP-1 activity

suppresses

cell

proliferation

in human colon carcinoma cells. Int J

Hu, W., Fan, C., Jiang, P., Ma, Z., Yan, X., Di,

Cancer, 124, 7- 15.

S., … Yang, Y. (2015). Emerging role of N-myc downstream-regulated gene 2

Kim, Y. J., Yoon, S. Y., Kim, J. T., Song, E. Y.,

(NDRG2) in cancer. Oncotarget, 7(1),

Lee, H. G., Son, H. J., … Kim, J. W. (2009).

209–223. doi: 10.18632/oncotarget.6228

NDRG2 expression decreases with tumor

Hu, W., Yang, Y., Fan, C., Ma, Z., Deng, C., Li,

stages and regulates TCF/beta-catenin

T., … Gao, J. (2016). Clinical and

signaling in human colon carcinoma.

pathological

Carcinogenesis, 30(4), 598–605. doi:

significance

N-Myc

downstream-regulated gene 2 (NDRG2) in

10.1093/carcin/bgp047

13 16

Kim, Y.S., & Deng, G. (2007). Epigenetic

Ma, Y., Wu, L., Liu, X., Xu, Y., Shi, W., Liang,

changes (aberrant DNA methylation) in

Y. (2017). KLF4 inhibits colorectal cancer

colorectal neoplasia. Gut Liver, 1(1), 1–11.

cell proliferation dependent on NDRG2

doi: 10.5009/gnl.2007.1.1.1

signaling. Oncol Rep, 38(2), 975-984.

Lauby-Secretan, B., Vilahur, N., Bianchini,

Marley, A. R., & Nan, H. (2016). Epidemiology

F., Guha, N., Straif, K. (2018). The IARC

of colorectal cancer. International journal

perspective on colorectal cancer screening.

N Engl J Med, 378(18), 1734-1740.

genetics, 7(3), 105–114

Lech, G., Słotwiński, R., Słodkowski, M.,

Melotte,

molecular V., Qu,

epidemiology X., Ongenaert,

and M., van

Krasnodębski, I. W. (2016). Colorectal

Criekinge, W., de Bruïne, A. P., Baldwin,

cancer tumour markers and biomarkers:

H. S., van Engeland, M. (2010). The N-

Recent

myc downstream regulated gene (NDRG)

therapeutic

advances. World

journal of gastroenterology, 22(5), 1745–

family:

diverse

functions,

multiple

1755. doi:10.3748/wjg.v22.i5.1745

applications. FASEB J, 24(11), 4153-66. doi: 10.1096/fj.09-151464.

Li, S., Huang, S. M., Lim, J., Kim, J. (2008).

Piepoli, A., Cotugno, R., Merla, G., Gentile, A.,

Expression profiling of the differentiation downstream

Augello, B., Quitadamo, M., … Andriulli,

regulated gene 2 in normal human tissues.

A. (2009). Promoter methylation correlates

Basic and Applied Pathology, 1, 77-82.

with reduced NDRG2 expression in

Littlechild, J., Junejo, M., Simons, A. M.,

advanced colon tumour. BMC medical

Curran, F., & Subar, D. (2018). Emergency

genomics, 2, 11. doi:10.1186/1755-8794-

resection surgery for colorectal cancer:

2-11

protein

N-myc

and

Pisano, M., Zorcolo, L., Merli, C., Cimbanassi,

survival. World journal of gastrointestinal

S., Poiasina, E., Ceresoli, M., … Ansaloni,

pathophysiology, 9(1),

L. (2018). 2017 WSES guidelines on colon

Patterns

recurrent

disease

8–17.

and rectal cancer emergencies: obstruction

doi:10.4291/wjgp.v9.i1.8

and

Lorentzen, A., & Mitchelmore, C. (2017).

perforation. World

journal

NDRG2 gene copy number is not altered in

emergency surgery : WJES, 13, 36.

colorectal carcinoma. World J Clin Oncol,

doi:10.1186/s13017-018-0192-3 Prenen, K., & Prenen, H. (2015). Oncological

8(1), 67–74.

emergencies

associated

Saebø, M., Skjelbred, C. F., Godiksen,

gastrointestinal

tumors. Annals

S., … Mitchelmore, C. (2007). Expression

gastroenterology, 28(4), 426–430.

Lorentzen, A., Vogel, L. K., Lewinsky, R. H.,

with of

of NDRG2 is down-regulated in high-risk

Renzi, C., Lyratzopoulos, G., Card, T., Chu, T.

adenomas and colorectal carcinoma. BMC

P., Macleod, U., & Rachet, B. (2016). Do

Cancer, 7, 192.

colorectal cancer patients diagnosed as an emergency differ from non-emergency 14 17

patients in their consultation patterns and

(2017). Genetic and epigenetic markers in

symptoms? A longitudinal data-linkage

colorectal

study in England. British journal of

advances. Expert Review of Molecular

cancer, 115(7),

Diagnostics,

866–875.

doi:10.1038/bjc.2016.250 November

screening:

17(7),

recent

665-685.

doi:

10.1080/14737159.2017

RevMan 5 | Cochrane Community. (n.d.). Retrieved

cancer

2019,

Steele, R. J. C., & McDonald, P. (2014).

from

Screening

for

colorectal

cancer.

In:

https://community.cochrane.org/help/tools

Scholefield JH, Eng C, editor. Colorectal

-and-software/revman-5

Cancer

Rex, D. K., Boland, C. R., Dominitz, J. A.

Diagnosis

and

Clinical

Management. United Kingdom: John

(2017). Colorectal Cancer Screening:

Wiley & Sons, Ltd, pp 17-40.

Recommendations for Physicians and

Swiderska, M., Choromańska, B., Dąbrowska,

Patients from the U.S. Multi-Society Task

E.,

Force on Colorectal Cancer. Am J

Choromańska, K., Szczurko, G., … Zwierz,

Gastroenterol, 112(7), 1016-1030.

K. (2013). The diagnostics of colorectal

Shen, L., Qu, X., Li, H., Xu, C., Wei, M., Wang,

Konarzewska-Duchnowska,

E.,

cancer. Contemp Oncol (Pozn), 18(1), 1–6.

W., … Zhang, J. (2018). NDRG2

doi: 10.5114/wo.2013.39995

facilitates colorectal cancer differentiation

Vaes, N., Schonkeren, S. L., Brosens, E., Koch,

through the regulation of Skp2-p21/p27

A., McCann, C. J., Thapar, N., … Melotte,

axis. Oncogene, 37(13), 1759–1774.

V. (2018). A combined literature and in

Shen, L., Qu, X., Ma, Y., Zheng, J., Chu, D.,

silico analysis enlightens the role of the

Liu, B., … Zhang, J. (2014). Tumor

NDRG family in the gut. Biochim Biophys

suppressor NDRG2 tips the balance of

Acta Gen Subj, 1862(10), 2140-2151. doi:

oncogenic TGF-β via EMT inhibition in

10.1016/j.bbagen.2018.07.004

colorectal cancer. Oncogenesis, 3(2), e86.

Wang, J. H., King, T. M., Chang, M. C., & Hsu,

doi: 10.1038/oncsis.2013.48.

C. W. (2012). Oxaliplatin-induced severe

Shi, H., Jin, H., Chu, D., Wang, W., Zhang,

anaphylactic

reactions

J., Chen, C. (2009). Suppression of N-myc

colorectal

cancer:

case

series

downstream-regulated gene 2 is associated

analysis. World

journal

with induction of Myc in colorectal cancer

gastroenterology, 18(38),

and correlates closely with differentiation.

doi:10.3748/wjg.v18.i38.5427

Diagnostic

(2009).

E., Mallett, S., Deeks, J. J., Reitsma, J.

Basic

B., … Bossuyt, P. M. M. (2011).

Measures

Accuracy:

5427–5433.

Whiting, P. F., Rutjes, A. W. S., Westwood, M.

Biol Pharm Bull, 32(6), 968-75. Šimundić

metastatic

Definitions. EJIFCC, 19(4), 203–211.

QUADAS-2: A revised tool for the quality

Singh, M. P., Rai, S., Suyal, S., Singh, S. K.,

assessment of diagnostic accuracy studies.

Singh, N. K., Agarwal, A., Srivastava, S.

Annals of Internal Medicine, 155(8), 529– 15 18

536.

https://doi.org/10.7326/0003-4819-

155-8-201110180-00009 Xu, X., Li, J., Sun, X., Guo, Y., Chu, D., Wei, L., â&#x20AC;Ś Shen, L. (2015). Tumor suppressor NDRG2

inhibits

glycolysis

and

glutaminolysis in colorectal cancer cells by repressing c-Myc expression. Oncotarget, 6(28),

26161â&#x20AC;&#x201C;26176.

doi:

10.18632/oncotarget.4544. Yamamura, A., Miura, K., Karasawa, H., Motoi, F., Mizuguchi, Y., Saiki, Y. (2017). NDRG2, suppressed expression associates with poor prognosis in pancreatic cancer, is hypermethylated in the second promoter in human gastrointestinal cancers. Biochem Biophys Res Commun, 484(1), 138-143. Zamani, M., Hosseini, S. V., Mokarram, P. (2018).

Epigenetic

biomarkers

colorectal cancer: premises and prospects. Biomarkers,

23(2),

105-114.

doi:

10.1080/1354750X.2016.1252961 Zhang, J., Li, X., Shen, L., Li, Y., Yao, L. (2019). N-Myc Downstream-Regulated Gene 2 (NDRG2) as a Novel Tumor Suppressor in Multiple Human Cancers. IntechOpen, 1-16.

16 19

Appendices Table 1. Characteristics of Included Studies Author, Year

Chu, 2011

Country

China

Study Design

Cohort

Patients’ Characteristics

Age Mean: 58.2 (2181) ≤60: 128 >60: 98 Gender Male: 187 Female: 39 BMI, kg/m2 ≤25: 121 >25: 105

Sample Size

NDRG2 Promoter Methylation

CRC

Normal

CRC: 226 Control: 36 (noncancerous, healthy colon mucosa tissues from patients without malignancy)

CRC: 70 Control: 70 (paired adjacent non-

45/70

11/70

NDRG2 Promoter Methylation Based on Clinicopathological Data

Tumor Differentiation Status -

Tumor Stage

Tumor Location

TNM Stage I/II/III: 24/30 IV: 21/40

Promoter Methylation Analysis Method

NDRG2 Expression

NDRG2 Expression Based on Clinicopathological Data

Gene Expression Analysis Method

CRC

Normal

Tumor Differentiation Status

Tumor Stage

Well: 21/46 Moderately/ Poor: 49/180 (p<0.001)

TNM Stage I: 22/56 II: 23/41 III: 21/105 IV: 4/24 (p<0.001)

RT-PCR

MSP

27/70

64/70

IHC

Smoking Status Never smoker: 98 Ex-smoker: 86 Current smoker: 42

Feng, 2011

China

Case Control

Follow-up 38 months -

Well: 10/26 Moderately/ Poor: 35/44 (p=0.002)

2 20

neoplastic tissues)

Hong, 2016

Korea

Case Control

Kim, 2009

Korea

Case Control

Age <50: 37 ≥50: 62 Gender Male: 48 Female: 51

Ma, 2017

China

Case Control

Age Mean: 64 (16-85) <60: 53 ≥60: 48 Gender Male: 62 Female: 39

CRC: 27 Control: 27 (paired adjacent noncancerous tissues) CRC: 99 Control: 99 (normal distant tissue from the tumor lesion)

CRC: 101 Control: 101 (paired normal mucosal tissues)

(p=0.017)

24/27

2/27

T Stage I/II: 3/4 III: 20/22 IV: 1/1 (p=0.039)

Proximal: 13/13 Distal: 11/14

MSP

3/27

24/27

44/99

99/99

Well: 23/28 Moderately/ Poor: 21/71 (p<0.0001)

Well: 30/59 Moderately/ Poor: 22/42 (p=0.014)

RT-PCR

Invasion Depth T1: 3/3 T2: 14/18 T3: 24/72 T4: 3/6 (p=0.0015)

IHC

Dukes’ Stage A: 15/17 B: 9/27 C: 20/55 WHO Stage: I: 20/38 II: 28/51 III: 4/12 (p=0.021)

IHC

3 21

Piepoli, 2009

Italy

Case Control

Age <50: 9 â&#x2030;Ľ50: 21 Gender Male: 15 Female: 15

Shen, 2014

Shi, 2009

Xu, 2015

Yamamura, 2017

China

Japan

Case Control

Age <60: 167 >60: 143 Gender Male: 165 Female: 145 Age <60: 48 â&#x2030;Ľ60: 102 Gender Male: 89 Female: 61 Age <60: 35 >60: 33 Gender Male: 38 Female: 30 -

MSP

12/50

38/50

Well: 9/19 Moderately/ Poor: 5/31 (p<0.001)

29/ 150

121/ 150

Well: 18/70 Moderately/ Poor: 11/80 (p=0.005)

IHC

Well: 15/15 Moderately/ Poor: 33/53 (p<0.001)

IHC

6/25

19/25

IHC

CRC: 30 Control: 30 (paired normal mucosal tissues)

8/30

0/30

CRC: 50 Control: 50 (adjacent normal mucosal tissues)

18/24

6/24

CRC: 150 Control: 150 (paired normal mucosal tissues) CRC: 68 Control: 68 (adjacent normal mucosal tissues)

CRC: 25 Control: 25 (correspondi ng normal mucosal tissues)

TNM Stage: 0: 1/1 I: 1/3 II: 1/8 III: 0/3 IV: 6/14 (p<0.05) -

TNM Stage: I-II: 7/8 III: 5/16 IV: 2/26 (p<0.001)

IHC

Abbreviations: CRC, Colorectal Cancer; IHC, Immunohistochemistry; MSP, Methylation Specific PCR; RR, Relative Risk; RT-PCR, Reverse Transcriptase-Polymerase Chain Reaction

4 22

Table 2. Quality Assessment of Included Studies Study

RISK OF BIAS PATIENT SELECTION

Chu, 2011 Feng, 2011 Hong, 2016 Kim, 2009 Ma, 2017 Piepoli, 2009 Shen, 2014 Shi, 2009 Xu, 2015 Yamamura, 2017

JLow Risk

INDEX TEST

J J L J L J L J L J L J L J L J L J L J LHigh Risk

APPLICABILITY CONCERNS

REFERENCE STANDARD

FLOW AND TIMING

PATIENT SELECTION

INDEX TEST

REFERENCE STANDARD

J J J J J J J J J J

? Unclear Risk

Table 3. Subgroup Analyses of NDRG2 Expression to Detect Colorectal Cancer Based on Tumor Differentiation Status Model

P (I2)a

Effect Size b (95% CI)

IHC

REM

0.003 (75%)

0.35 [0.23 – 0.55]

< 0.00001

RT-PCR

FEM

0.45 [0.23 – 0.87]

0.02

Characteristics Method of Genotyping

Overall significance test among subgroups

0.58

Control Tissue Normal tissue from

FEM

0.45 [0.23 – 0.87]

0.02

Paired normal tissue

FEM

0.15 (51%)

0.71 [0.40 – 1.26]

0.24

Adjacent normal tissue

FEM

0.35 (0%)

0.13 [0.04 – 0.44]

0.0009

Distant normal tissue

FEM

0.09 [0.03 – 0.27]

< 0.0001

patients without malignancy

Overall significance test among subgroups

0.002

Abbreviation: FEM, Fixed Effect Model; IHC, Immunohistochemistry; NA, Not applicable (because of low number of included studies); RT-PCR, Reverse Transcriptase Polymerase Chain Reaction a

Heterogeneity among studies

Odds ratio

Table 4. Subgroup Analyses of NDRG2 Expression to Detect Colorectal Cancer Based on Tumor Staging Model

P (I2)a

Effect Size b (95% CI)

IHC

REM

0.002 (80%)

0.32 [0.18 – 0.57]

0.0001

RT-PCR

FEM

0.61 [0.32 – 1.14]

0.12

Characteristics Method of Genotyping

Overall significance test among subgroups

0.14

Control Tissue Normal tissue from

FEM

0.61 [0.32 – 1.14]

0.12

Paired normal tissue

FEM

0.93 [0.41 – 2.08]

0.86

Adjacent normal tissue

FEM

0.03 [0.00 – 0.27]

0.02

Distant normal tissue

FEM

0.82 (0%)

0.08 [0.02 – 0.31]

0.0003

patients without malignancy

Overall significance test among subgroups

0.001

Tumor Staging System TNM

REM

0.02 (74%)

0.40 [0.23 – 0.70]

0.001

WHO

FEM

0.93 [0.41 – 2.08]

0.86

Dukes’

FEM

0.07 [0.02 – 0.34]

0.07

Overall significance test among subgroups

0.01

Abbreviation: FEM, Fixed Effect Model; IHC, Immunohistochemistry; NA, Not applicable (because of low number of included studies); REM, Random Effect Model; RT-PCR, Reverse Transcriptase Polymerase Chain Reaction a

Heterogeneity among studies

Odds ratio

Modifiable Survival Factors of Out-of-hospital Cardiac Arrest among Global Population: Systematic Review and Meta-analysis of Large Cohort Trials Jeremy Rafael Tandaju1*, Kareen Tayuwijaya1 1

Undergraduate program, Faculty of Medicine, Universitas Indonesia *jeremy.rafael@ui.ac.id,

(+62) 817 6540365

Asian Medical Students’ Association Indonesia Introduction: Cardiac arrest is leading cause of death contributing up to 10,000,000 deaths per year and up to 3,750 USD burden per-household. Out-of-hospital cardiac arrest (OHCA) is the most common and deadly type. Currently, cardio-pulmonary resuscitation (CPR) is most important for survival thus implemented, but death toll is still high. We believed that OHCA survival should be multi-discipline action. Aim: Reduce OHCA’s mortality and morbidity by modification of survival factors found in this study, thus improve its prognosis and reduce one third of premature death as aimed by The United Nations by 2030. Methods: We conducted systematic review and meta-analysis of large cohort studies (n>100,000) on general populations’ OHCA survival. Studies were acquired from four databases (n=3,560), filtered then appraised with Newcastle-Ottawa scale for quality and Cochrane risk-of-bias (n=9). Subsequently, assessed for full text and synthesized to analysis. Results: Among 486,012 subjects, we found out that age and shockable rhythm is unmodifiable but could be helped with lifestyle. Modifiable factors are grouped into two: bystander response including public location (OR=1.24; CI 95%=1.16–1.32), bystander witness (OR=1.45; CI 95%=1.36–1.56), bystander CPR (OR=1.45; CI 95%=1.36–1.56); and emergency service delivery including paramedic response <10 minutes (OR=1.55; CI 95%=1.41–1.70), ambulance physician (OR=1.52; CI 95%=1.37–1.68). Discussion: People having OHCA on public location have higher probability to get immediate CPR from bystanders. However, some studies shown that CPR is sometimes unfavorable due to lack of CPR knowledge, thus public education about CPR is needed. Besides, emergency services are important to arrive in time with competent workers, preferably physicians who are well-trained of defibrillator usage and OHCA medication regiment which could increase chance of surviving OHCA. Therefore, increase awareness of emergency medical systems’ presence, maintain good ratio of ambulance-to-population, and training health care workers for emergency conditions are essentially needed. Conclusion: OHCA survival depends on collaboration of nation: bystanders, emergency workers, inhospital workers; thus, every element should expand their own knowledge of OHCA management. This

effort along with perfection and publication of emergency medical service will increase survival of OHCA. More area-specified and factor-specified studies should be conducted to improve applicability.

Modifiable Survival Factors of Out-of-hospital Cardiac Arrest among Global Population: Systematic Review and Meta-analysis of Large Cohort Trials

Scientific Paper

Jeremy Rafael Tandaju Kareen Tayuwijaya 21

Faculty of Medicine Universitas Indonesia September 2019

1 Modifiable Survival Factors of Out-of-hospital Cardiac Arrest among Global Population: Systematic Review and Meta-analysis of Large Cohort Trials Jeremy Rafael Tandaju1*, Kareen Tayuwijaya1 1

Undergraduate program, Faculty of Medicine, Universitas Indonesia *jeremy.rafael@ui.ac.id,

(+62) 817 6540365

Asian Medical Students’ Association Indonesia

1. Introduction Cardiac arrest is phenomenon of sudden electrical distortion in heart, whether in pacemaker and/or bundles which disturb heart activity. Cardiac arrest should be differentiated from heart attack, in which there is a blockage in vascular systems which triggers electrical rhythm changes leading to cardiac arrest. Cardiac arrest is usually caused by arrhythmia, an irregular rhythm of heart which is not dangerous on a short term, however extremely dangerous if prolonged. Some causes of arrhythmia including coronary artery disease, heart attack, cardiomyopathy, valvular heart disease, congenital heart disease, and various electrical problems in heart such as Brugada’s syndrome and long QT syndrome (Longo et al., 2012, p. 328–30). These causes are burdened by such conditions as personal and/or family history, smoking, and metabolic disorders. Cardiac arrest will reduce blood flow to brain leading to unconsciousness and brain damage if rhythm does not return to normal state. Brain damage will be followed by death as the worst complication (Yang et al., 2015, p. 1941–2). All of these take place in matter of minutes, in which chance of survival reduce by 10% each minute patients left unattended or without any bystanders (Longo et al., 2012, p. 334). Cardiac arrest could be caused by ischemic heart disease, which is world’s leading cause of death in 2016, contributing up to 10,000,000 deaths per year (WHO, 2016). It is also estimated in The United States that ischemic heart disease leads to cardiac arrest which kills more than 325,000 people yearly which are more to combination of breast cancer, lung cancer, and HIV/AIDS death toll. Cardiac arrest also causes economic burden of approximately USD 3,750 (IDR 53,000,000) per taxpayer family in The United States (Newman M, 2018). Indonesian fact sheets on 2018 also shown that cardiac arrest due to coronary heart disease contributed to 12.9% of national death, which is the highest and recently well distributed among all group of aged above 44 years which means every middle age and older share the risk almost equally (Indonesia Health Research, 2018). Out-of-hospital cardiac arrest (OHCA) is one example of cardiac arrest, involving emptiness of systemic circulation and mechanical cardiac function loss. It is estimated that 356,461 OHCA occur every year in The United States, which build up to 55% of all cardiac arrest events in which 90% of them are

2 deadly (Newman M, 2018). This type of arrest is the most prone to continual brain cell death because of lack of perfusion. Various ways have been taken in order to increase survival of OHCA such as training to emergency health care workers and general populations. Even though it has positive impact on neurological outcomes, OHCA survival rate is still low as only less than 10% OHCA patient will survive (Myat A, 2018, p. 911). Prior to latest knowledge, time for cardio-pulmonary resuscitation (CPR) holds most impact on OHCA survival. However, a successful OHCA management is based on chain of survival involving public bystanders, emergency services, and in-hospital providers (Riva et al., 2019, p. 2606â&#x20AC;&#x201C;7). Based on current knowledge, importance, urgency, and multi-aspects of OHCA management, we decided to study modifiable survival factors prior to OHCA in-hospital survival rate in order to take further steps in reducing mortality and morbidity of OHCA and to improve its prognosis. It is also aimed to support sustainable development goals of United Nation which targeted to reduce by one third premature mortality from non-communicable diseases such as cancer, diabetes, respiratory disease, including cardiovascular disease by 2030 using multi-disciplinary approach in the dimension of public, emergency service, and hospital providers (United Nations, 2015). This study is also aimed to encourage Indonesia, as place where this study is conducted to increase its emergency response towards OHCA by focusing on factors which will be found on this study. 2. Methods 2.1. Search strategy We conducted systematic review of cohort studies which focused on general population who experienced OHCA as populations, survival factors as indicator with their respective controls, and survival rate as its outcome. We conducted a qualitative research guided by Cochraneâ&#x20AC;&#x2122;s handbook (Higgins et al., 2011). We conducted searching on four databases: PubMed, Scopus, ProQuest, and ScienceDirect using queries which could be seen in table 1. Table 1. Search strategies on various databases. Database

Queries

PubMed

(((((Factor[Title/Abstract]) (((("Survival"[Mesh]

Findings OR

Factors[Title/Abstract]))) "Survival

Rate"[Mesh]))

AND 617 OR

"Survival"[Title/Abstract]) OR "Survival Rate"[Title/Abstract])) AND (("Out-of-Hospital Cardiac Arrest"[Mesh]) OR "Out-of-Hospital Cardiac Arrest"[Title/Abstract])

3 Scopus

((“Factor” OR “Factors”) AND (“Survival” OR “Survival Rate” OR 1,470 “Survive Rate”) AND (“Out-of-Hospital Cardiac Arrest” OR “OHCA”))

ProQuest

((“Factor” OR “Factors”) AND (“Survival” OR “Survival Rate”) AND 4,554 (“Out-of-Hospital Cardiac Arrest” OR “OHCA”))

ScienceDirect ((“Factor” OR “Factors”) AND (“Survival” OR “Survival Rate”) AND 5,268 (“Out-of-Hospital Cardiac Arrest” OR “OHCA”)) 2.2. Inclusion and exclusion criteria Search results were assessed for duplication, which further assessed, including studies which mentioned OHCA. Studies then filtered using inclusion and exclusion criteria. Inclusion criteria are: (a) cohort/followup/population-based studies (b) general population (c) studying factors contributing to OHCA survival. Exclusion criteria are: (a) disease-centered outcome (b) studying general cardiac arrest (c) full text in other language due to researchers’ limitation to hire a translator. Holistic process of literature research could be seen in figure 1. Criteria were fitted by two reviewers independently. Any disagreements are discussed together and resolved within two authors to reach agreements.

Scopus n = 1,470

ProQuest n = 4,554

Identification

PubMed n = 617

ScienceDirect n = 5,268

Duplication removal n = 8,349 Studies acquired n = 3,560

Eligibility

Screening

Screening: OHCAoriented studies

Inclusion criteria: Cohort/follow-up studies, involving general population, studying OHCA survival

Excluded: mortality as outcome (4), qualitative study (1), samples are >80 years old (1)

Records screened n = 517

Full text assessed for eligibility n = 16

Exclusion criteria: Disease-centered outcome, study age of >20 years, full text in other languages

Included

Studies included in qualitative synthesis (systematic review) n=9

Public location of OHCA n=5 Bystand witness of OHCA n=7

Studies included in quantitative synthesis (metaanalysis) n=9

Bystand CPR n=8 Paramedic response n=7

Ambulance doctor n=5

Figure 1. Search strategy and flow of literature search.

5 2.3. Quality Assessment All nine studies are assessed further using Newcastle-Ottawa scale which converted to Agency of Healthcare Research Quality (AHRQ) standard into good, fair, or poor quality (Luchini et al., 2017,p. 82). Quality assessment using Newcastle-Ottawa scale was done with two reviewers assessed all studies respectively, which each other are blinded on others’ scoring, then discussed further after scoring was done. In addition, studies were also assessed for risk of bias using revised Cochrane risk-of-bias tool with two reviewers also blinded and results discussed after assessment (Higgins et al., p. 1–66). 2.4. Qualitative and quantitative analysis We used evidence-based analysis to conduct a systematic review. two reviewers assessed studies’ outcome and highlight significant contributing factors to intra-hospital survival of OHCA independently, then discussed further which resulted in form of a table. Studies will be extracted by source, location, design, number of participants, mean age, gender, follow-up period, drop-out rate, and outcome. Agreed factors will be discussed by reviewers with regards to relation strength and mechanisms. Factors which are sufficient for quantitative analysis are admitted for meta-analysis. Factors were put as study code, log of odds ratio, and standard of error which will be calculated for study weight, fixed odds ratio and its 95% confidence interval (CI) which will be presented in forest plot. Studies were also assessed for statistical heterogeneity using chi-squared test which samples would be considered heterogenous if p-value is greater than 0.05 and using I-squared statistic which would be considered heterogenous below 50% level according to the Cochrane handbook (Ahn et al., 2018, p. 108). Heterogeneity assessment’s results will be presented in funnel plot. All qualitative statistical analyses were done using Review Manager software for iOS. 3. Results 3.1. Literature search We conducted a literature search using search strategy mentioned above and found 3,560 studies after duplication removed from PubMed, Scopus, ProQuest, and ScienceDirect. We filtered studies based on inclusion and exclusion criteria and finally retrieved 16 studies which were further assessed by full-textreading. However, four studies which presented mortality instead of survival as outcome, one study with geriatric samples, and one study with qualitative design were thus omitted and we came to a total 9 studies assessed for both qualitative and quantitative analysis.

3.2. Study characteristics We found nine studies which consisted of three retrospective and six prospective cohort studies across three continents: Asia (n=4), Europe (n=3), and America (n=2). This study involved >100,000 samples with >1,000 samples from each study, thus considered as meta-analysis of large cohort trials (Higgins et al., 2011). This study collected data from 486,012 subjects with various characteristics which have been analyzed and proven there are no chance of these characteristics to be confounding factor as they are distributed equally when the studies started as in table 2. They are mean age which distributed among >55 years, sex which was slightly to moderately dominated by male, and level of evidence which distributed among 2aâ&#x20AC;&#x201C;1b. However, there are deviance in drop-out rate by Liu et al. (2008) and length of follow up by Mathiesen et al. (2018) but do not give negative effect to the study as those studies were classified as good studies by Newcastle-Ottawa scale. This scale also has proven studies were in good condition to be assessed, even reaching full points of excellent for all studies beside of study by Liu et al. (2008), and all appraised studies were in low risks of bias according to Cochrane tools which could be seen clearly in table 3. However, studies which accumulated altogether are subject to risk of publication bias which will be explained further. 3.3. Factors contributing to survival of OHCA Based on qualitative review of two reviewers, we concluded that factors contributing to OHCA intrahospital survival could be classified as unmodifiable and modifiable, as seen in Table 4. Unmodifiable factors were older age which contributed negatively to survival according to all nine studies and shockable rhythm which contributed positively in six studies, while sex did not have any clear relation. However, we were more concerned about modifiable factors which mainly focused on multi-disciplinary actions of emergency medicine involving health care workers, emergency team, and public bystanders. These include public location as mentioned in five studies, bystander witness in seven studies, bystander CPR in eight studies, paramedic response <10 minutes in seven studies, advanced life support (ALS) skill in one study, return of spontaneous circulation unit at emergency department in one study, physician in ambulance in five study which all correlated positively to survival in addition with drug given on transport.

ABSTRACT KETAMINE Versus MIDAZOLAM as immediate Management In Acute Suicidal State: A Systematic Review and Meta-Analysis *Moh Anfasa Giffari M, A. Fitri Febrianty Fariadi, Nadhifah Nurul Muthiah, Ahmad Taufik Fadillah Z. *fasagifari@gmail.com Aim: This review is conducted to conclude the difference outcome between ketamine versus midazolam as immidiate management in acute suicidal state. Results are hoped to increase public awareness for suicide among public safe community. Introduction: Suicide is a global emergency that can cause death by injuring oneself with the intent to die. Deaths caused by suicide have increased worldwide. According to World Health Organization (WHO) in 2018, globally there are 800,000 people who die from suicide each year with an estimated at least 1 person who died from suicide every 40 seconds worldwide. Recently has received considerable attention in psychiatric research. Ketamine studies showed us that rapid improvement in complex mood states such as depression, and suicidality are possible with therapeutic interventions. Matherials and Methods: This Systematic Review is based on Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) and organized adhering to previously recommended guidelines for transparent and comprehensive reporting of methodology and result. Results: From 4 database of journal, total a preliminary search obtained 229 articles and final 4 studies were included in meta-analysis. We compared the pooled effect size of Ketamine on Patient with suicidal ideation to control conditions in a fix-effects model. Moderate pooled effect size was observed (4 studies, n=127, z=3.27, 95% CI: -6.34-1.59, p=0.001). Conclusion : In conclusion, we found that across 4 controlled trials with 72 total participant a single ketamine infusion rapidly reduced the severity of suicidal Ideation within 24 hour compare with common modality antidepressant midazolam, based on reduction in SSI Score. It may be an acceptable and effective treatment for rapid relief of suicidal ideation. Keywords: Ketamine, Suicidal Ideation, Systematic Review, Meta-Analysis.

KETAMINE Versus MIDAZOLAM as immediate Management In Acute Suicidal State: A Systematic Review and Meta-Analysis Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2020

By: Moh. Anfasa Giffari M* A. Fitri Febrianty Fariadi Nadhifah Nurul Muthiah Ahmad Taufik Fadillah Zainal Faculty of Medicine Hasanuddin University Makassar

Here, we performed systematic review and meta-

INTRODUCTION

analysis to compare the effectiveness between Ketamine

Suicide is a death caused by injuring oneself with

versus Midazolam to treating patients physiatric disorder

the intent to die. A suicide attempt is when someone harms

with acute suicidal ideation. This systematic review

themselves with the intent to end their life, but they do not

present some level data of explicit measures of suicidal

die as a result of their actions (CDC, 2019). More than

ideation to assess ketamine’s potential anti-suicidal effects

90% of people who commit suicide suffer psychological

to be modality for suicidal ideation.

disorders, most commonly depression (Durand & Barlow, 2003). Among the stages in developing suicide, suicide

MATERIAL AND METHODS

ideation is one of them, the idea of suicide is a process of

This Systematic Review is based on Preferred

contemplation of the concept of suicide or a process that

Reporting Items for Systematic Reviews and Meta-

is passed without taking action, where a person will not

analyses statement (PRISMA) and organized adhering to

express his thoughts for suicide if it is not forced (Captain,

previously recommended guidelines for transparent and

C. 2008).

comprehensive reporting of methodology and result. To

Deaths caused by suicide have increased

add referances, this research collected data based on

worldwide. According to World Health Organization

reference with relevant study types which either have been

(WHO) in 2018, globally there are 800,000 people who

published or unpublished

die from suicide each year with an estimated at least 1

Search Strategy

person who died from suicide every 40 seconds worldwide (WHO, 2018). In Indonesia there are 7,335 suicide cases

Three reviewers (A.M ,F.A & N.N) search this

with an incidence of 3 per 100,000 population and is

review using online search engineering with database:

believed to continue to increase each year (WHO, 2017).

PubMed, MEDLINE, PsyIndex, US Clinicial Trials with

Suicide prevention steps are very important and

using terms “Ketamine” and “Suicidal Ideation”.

recommended in the strategy of developing and Eligibility Criteria

implementing a degrade in suicide rates. Various treatments have been used in preventing

Eligible studies are randomized controlled trials

suicides including hospitalization, dialectical behavioral

(RCTs) that includes participants of neuropshyciatric

therapy (DBT), and cognitive behavioral therapy (CBT)

disorder with suicidal ideation, which used Ketamine as

(Turecki & Brent, 2016). Recently, Ketamine a glutamate

the intervention and Suicide Ideation Scale based on Scale

N-methyl-D-aspartate receptor (NMDA-R) antagonist has

for Suicidal Ideation (SSI) for evaluation. The Control

received considerable attention in psychiatric research as

group receive either placebo (normal saline) or

a prototype for a new generation of antidepressants after

Midazolam, a general modality for depression. Only

the discovery of its profound and rapid effects on

english literatures were reviewed for this study. Three

depressive symptoms the utility is targeting the

independent reviewers (A.M ,F.A & N.N) screened the

glutamatergic system, a truly novel antidepressant

title and abstracts to identify eligible studies. Studies that

mechanism. Ketamine studies showed us that rapid

administered multiple ketamine doses were excluded.

improvement in complex mood states such as depression,

Quality Assessment

and suicidality are possible with therapeutic interventions.

To evaluate the risk of bias in selection,

(Abdallah, Averill, & Krystal, 2015).

performance, detection, attrition, and outcome reporting, this study utilizes Review Manager 5.3. Results are then 37

classified into high, low, or unclear for risk of bias. Three

Effect sizes were calculated using mean differences

authors (A.M ,F.A & N.N) evaluate the risk of bias

between baseline and each time point Days 1 post-

independently to form a summary.

infusion. For all analyses, significance was set I2> 50%, p≤0.05, if valuable heterogeneity was showed, random

Data Extraction

effect model would be used. If not, fixed effect model

Data from each journal is collected and then

would be done.

inputted into a table. Data taken were: 1) characteristics of Publication Bias and Additional Analyses

participants (sample size, age of participants and diagnostic information); 2) intervention features (study

The presence of publication bias was evaluated by

length, details of the control group and any additional

drawing a funnel plot. Additionally, for situations that the

intervention components); 3) scale treatment using Scale

heterogeneity is too large, Duval and Tweedie's trim-and-

for Suicidal Ideation (SSI). If there’s any incomplete data,

fill analysis was conducted to re-calculate the pooled

the researcher will contact the author by e-mail to retrieve

effect size after removing any studies which may

the data, no response from the author will exclude the

introduce publication bias (i.e., small studies with large

corresponding study.

effect sizes from the positive side of the funnel plot) (Duval and Tweedie, 2000), and “fail-safe N” was used to

Statistical Analysis

account for the file draw problem (Orwin, 1983),

All analysis were conducted by Review Manager

estimating the number of negative results which would be

5.3. Researcher did meta-analysis with Patient-level data

required to invalidate the current meta-analysis.

that were collected from several distinct variables, RESULT

including: 1) suicidal ideation, assessed via Scale for Suicidal Ideation (SSI); 2) overall severity of depressive

A preliminary search obtained 229 articles. 53

symptoms, assessed via SSI total scores); 3) treatment

duplicate articles were removed. Then, authors read the

assignment (ketamine or control); and 4) potential

title and abstract of remaining 176 articles for preliminary

moderators of treatment effect (sample size, age of

screening. Author excluded literatures with reason,

participants and diagnostic information). Whenever

including a literatures published below range of ten years,

available, all data were collected from each investigator

other study design (animal expleriment, case report, editor

for baseline and Days 1 of acute post-ketamine.

response, protocol, review and related meta-analysis), literature without compare, and all literature without

Because this study sought to determine the effects

outcome. Finally, full texts were retrieved for 14 papers

of ketamine on suicidal ideation, subjects with no suicidal

and comes 4 studies include for qualitative and

ideation at baseline were excluded from the analysis.

quantitative syntehesis of Meta-Analysis (Sinyor et al.,

Based on prior literature, we included active or passive

2018; Fan et al., 2016; Murrough et al., 2015; Price et al.,

suicidal ideation, which was operationalized a priori as a

2014). The literature screening process is shown in Fig. 1

self-report scales, suicidal ideation was defined as a or on SSI.

are otwo major scoring to scale suicidal ideation which is

Characteristic of included studies

Beck Scale for Suicidal Ideation (SSI/BSI) and

Full details of each study are displayed in Table

Montgomery Asberg Depression Rating Scale (Sinyor et

1. Outcome data were avaliable from 14 studies with

al 2018, Fan et al 2016, Murrough et al 2015, and Price et

Randomized Control Trial (RCT) with intervention

al 2014).

ketamine and Midazolam as control. Furthermore 10 there were 10 studies included all criteria that did not specify the

Risk of bias assessment

number of mean and standar deviation in outcome result

Result from Review Manager 5.3 for risk of bias

(Chen et al., 2019; Grunebaum et al., 2019;, Grunebaum

assessment are displayed in Fig. 2A & Fig. 2B. Show on

et al 2019; Canuso et al., 2018 Hu et al., 2016; Shelton et

the figure that the 4 study included show dominant low

al., 2015; Ballard et al., 2014; Zarate et al., 2012) which is

risk of bias.

impossible to include as meta-analysis papers, so that why reported outcome data only suited for 4 studies for meta-

Between-group effect of Ketamine and Midazolam in

analysis. Mean sample ages ranged from 18 to 65 years.

Patient with Suicidal Ideation

Subject in these studies is Patient with Treatment Resistant

We compared the pooled effect size of Ketamine on

Depression (TRD), Patient with Bipolar Depression (BD),

Patient with suicidal ideation to control conditions in a

and Patient with Major Depression Disorder (MDD)

fix-effects model. Moderate pooled effect size was

suicidal ideation Analysis (Sinyor et al 2018, Fan et al

observed (4 studies, n=127, z=3.27, 95% CI: -6.34-1.59,

2016, Murrough et al 2015, and Price et al 2014), that met

p=0.001) (see Fig. 3 for the forest plot). There was also a

Diagnostic and Statistical Manual of Mental Disorders-

moderate heterogeneity across the study data (p=0.4,

Four Edition (DSM-IV) (APA, 2000). Among them, there

I2=0). These results indicate that ketamine has shown to be

ideation and behaviors. Antidepressant and anti-suicidal

more effective in reducing rapid suicidal ideation

effects of ketamine a glutamate N-methyl-D-aspartate

compared to the general anti-depressant drug midazolam

receptor (NMDA-R) antagonist, were significantly seen as

which shows high significance (p = 0.001). There was

soon as 1 day following administration and typically lasted

moderate heterogeneity across the study data (p=0.4,

for at least 3 days.

I =0%), so we chose a fix-effects model. The funnel plot

The study did not detect significant increases of

is presented in Fig. 4 and Duval and Tweedie's trim-and-

treatment related emergency psychiatric symptoms in

fill analysis identified no outlier studies.

patients that received ketamine during the 7 days of follow-up observations. These findings indicate that ketamine is safe and effective for short term use at a subanesthetic dose of 0.5 mg/kg over 40 minutes. there are no available pharmacological agents having a similar time scale to that for ketamine, saline and midazolam are frequently-used as control agents in studying rapid-acting antidepressant effect. The results suggest that ketamine on SI may have more effect than midazolam, these based on suicidal ideation score from total 72 patients were reduce after 24 hours single ketamine infusion, this reduction was evaluated by Scale for Suicidal Ideation (SSI). The

DISCUSSION

signiďŹ cant reduction in suicidal ideation within 24 h is

This study review use individual participant-level

consistent with previous single-infusion ketamine studies

data to examine the effects of ketamine on suicidal

(mean= 1.13, SD= 2.65) (Price, 2014). This is promising

ideation, we found that patients treated with ketamine

as an early prevention of suicide to reduce the SI, since the

were significantly more likely to be free of suicidal

presence of suicidal thinking is a major risk factor of

ideation compare to midazolam in reducing suicidal

suicidal behavior, it stands to reason that reducing SI

ideation 24 h post-treatment. The fact that ketamine

would be linked to reduced suicide risk. However, since

infusion appears to be effective for reducing suicidal

ketamine response is often short-lived, question remain 41

regarding safety and efficacy both on long term effect and

ideation after ketamine infusion: Relationship to

repeated administration

reductions in depression and anxiety. Journal of Psychiatric

Limitations

Research,

58,

161–166.

https://doi.org/10.1016/j.jpsychires.2014.07.027

There are a few limitations in the current study.

Ballard, E. D., Luckenbaugh, D. A., Richards, E. M.,

Firstly, limited sample size, make our ability to estimate

Walls, T. L., Brutsché, N. E., Ameli, R., … Zarate,

the effects of ketamine on SI distinct from the effects of

C. A. (2015). Assessing Measures of Suicidal

ketamine on depression was limited. Secondly, limited of

Ideation in Clinical Trials with a Rapid-Acting

our review is lack of long-term observations of ketamine’s

Antidepressant. Journal of Psychiatric Research,

effect on depressive symptoms.

68,

68–73.

https://doi.org/10.1016/j.jpsychires.2015.06.003

CONCLUSION

Canuso, C. M., Singh, J. B., Fedgchin, M., Alphs, L., In conclusion, we found that across 4 controlled

Lane, R., Lim, P., … Drevets, W. C. (2018).

trials with 72 total participant a single ketamine infusion

Efficacy and Safety of Intranasal Esketamine for

rapidly reduced the severity of suicidal Ideation within 24

the Rapid Reduction of Symptoms of Depression

hour compare with common modality anti-depressant

and Suicidality in Patients at Imminent Risk for

midazolam, based on reduction in Scale of Suicidal

Suicide: Results of a Double-Blind, Randomized,

Ideation (SSI) Score. It may be an acceptable and effective

Placebo-Controlled Study. The American Journal

treatment for rapid relief of suicidal ideation.

175(7),

620–630.

https://doi.org/10.1176/appi.ajp.2018.17060720

RECOMMENDATION

Captain, C. (2008). Assessing suicide risk, Nursing made

Further research examining ketamine and similar

incredibly easy,6: p 46–53

compounds for the treatment of suicidal patients is

Chen, M.-H., Lin, W.-C., Wu, H.-J., Cheng, C.-M., Li, C.-

urgently needed, into ways to optimize ketamine dosing, administration,

Psychiatry,

and duration in order

T., Hong, C.-J., … Su, T.-P. (2019). Antisuicidal

to sustain

effect, BDNF Val66Met polymorphism, and low-

antidepressant beneﬁts.

dose ketamine infusion: Reanalysis of adjunctive

REFERENCES

ketamine study of Taiwanese patients with

Abdallah, C. G., Averill, L. A., & Krystal, J. H. (2015).

treatment-resistant depression (AKSTP-TRD).

Ketamine as a promising prototype for a new

Journal of Affective Disorders, 251, 162–169.

generation of rapid-acting antidepressants. Annals

https://doi.org/10.1016/j.jad.2019.03.075

of the New York Academy of Sciences, 1344, 66–

Durand, V.M., & Barlow, D.H. (2003). Essentials of

77. https://doi.org/10.1111/nyas.12718

Abnormal

Abstracts from the 37th Annual Meeting of the Society of 1,

2019,

(3rded.).

USA:

Wadsworth-Thompson Learning. Inc

General Internal Medicine. (n.d.). Retrieved October

Psychology

Duval, S., Tweedie, R., (2000). Trim and fill: a simple

from

funnel‐plot–based method of testing and adjusting

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC

for publication bias in meta‐analysis. Biometrics

4429500/

56, 455–463.

Ballard, E. D., Ionescu, D. F., Vande Voort, J. L., Niciu, M. J., Richards, E. M., Luckenbaugh, D. A., …

Fan, W., Yang, H., Sun, Y., Zhang, J., Li, G., Zheng, Y.,

Zarate, C. A. (2014). Improvement in suicidal

& Liu, Y. (2016). Ketamine rapidly relieves acute 42

suicidal ideation in cancer patients: A randomized

suicidal ideation: Preliminary experience in an

controlled clinical trial. Oncotarget, 8(2), 2356–

inpatient psychiatry setting. Journal of Affective

2360. https://doi.org/10.18632/oncotarget.13743

Disorders,

Grunebaum, M. F., Ellis, S. P., Keilp, J. G., Moitra, V. K.,

https://doi.org/10.1016/j.jad.2018.07.073

Cooper, T. B., Marver, J. E., … Mann, J. J. (2017).

Orwin, R.G., (1983). A fail-safe N for effect size in meta-

Ketamine versus midazolam in bipolar depression

analysis. J. Edu. Stat. 8, 157–159.

with suicidal thoughts: A pilot midazolam-

Turecki, G., & Brent, D. A. (2016). Suicide and suicidal

controlled randomized clinical trial. Bipolar Disorders,

behaviour.

176–183.

19(3),

(London,

England), 1227–1239.

https://doi.org/10.1016/S0140-6736(15)00234-2

Grunebaum, M. F., Galfalvy, H. C., Choo, T.-H., Parris,

World Health Organization. (2018). Suicide.

M. S., Burke, A. K., Suckow, R. F., … Mann, J. J.

World Health Organization. (2017). Suicide data reported

(2019). Ketamine metabolite pilot study in a

by countries.

suicidal depression trial. Journal of Psychiatric 129–134.

117,

Lancet

387(10024),

https://doi.org/10.1111/bdi.12487

Research,

103–109.

241,

Zarate, C. A., Brutsche, N. E., Ibrahim, L., Franco-

https://doi.org/10.1016/j.jpsychires.2019.08.005

Chaves, J., Diazgranados, N., Cravchik, A., …

Hu, Y.-D., Xiang, Y.-T., Fang, J.-X., Zu, S., Sha, S., Shi,

Luckenbaugh, D. A. (2012). Replication of

H., … Wang, G. (2016). Single i.v. ketamine

ketamine’s antidepressant efficacy in bipolar

augmentation of newly initiated escitalopram for

depression: A randomized controlled add-on trial.

major depression: Results from a randomized,

Biological

placebo-controlled 4-week study. Psychological

https://doi.org/10.1016/j.biopsych.2011.12.010.

Medicine,

APPENDIX

Murrough, J. W., Soleimani, L., DeWilde, K. E., Collins,

No Appendices needed in this review.

K. A., Lapidus, K. A., Iacoviello, B. M., … Charney, D. S. (2015). Ketamine for rapid reduction of suicidal ideation: A randomized controlled trial. Psychological Medicine, 45(16), 3571–3580. https://doi.org/10.1017/S0033291715001506 Price, R. B., Iosifescu, D. V., Murrough, J. W., Chang, L. C., Al Jurdi, R. K., Iqbal, S. Z., … Mathew, S. J. (2014). Effects of ketamine on explicit and suicidal

cognition:

randomized

controlled trial in treatment-resistant depression. Depression

and

Anxiety,

31(4),

335–343.

https://doi.org/10.1002/da.22253 Sinyor, M., Williams, M., Belo, S., Orser, B., Vincent, M., Mah,

Schaffer,

71(11),

623–635.

46(3),

https://doi.org/10.1017/S0033291715002159

implicit

Psychiatry,

(2018).

Ketamine

augmentation for major depressive disorder and

939–946.

Project title : Interleukin-6 for diagnosis of neonatal sepsis Name of University and Author : Andi Priscillia Al-qodri of Jambi University Febi Sofiana of Jambi University ABSTRACT Aim/background Neonatal sepsis is a dangerous and common disease among infants which is associated with high morbidity and mortality. Interleukins may be helpful for diagnosis of neonatal sepsis. Therefore, this study is conducted to investigate the role of interleukin 6 (IL-6) in the diagnosis of neonatal sepsis. Method In this study, databases including PubMed, EMBASE, and Google Scholar were searched up to 2019. Keywords were: Sepsis, neonatal, interleukins, prediction and diagnosis. Study inclusion criteria were: Articles about the relationship between the diagnosis of neonatal sepsis and interleukins; studies on babies; English articles and enough information from test results. Articles that had focused on adult sepsis or had used other markers except ILs or just their abstracts were available were excluded from the study. Of 100 searched studies, eventually, 6 articles has been selected for the review. Key findings The average values of IL-6 in the proposed studies showed that IL-6 above 67 pg/ml has 90% sensitivity and 70% specificity. IL-6 is a valid and primary predictive marker for neonatal infection which is relevant with severity of infection.

Interleukin-6 For Diagnosis of Neonatal Sepsis : A Systematic Review

Authors : Andi Priscillia Al-qodri Febi Sofiana

Faculty of Medicine Universitas Jambi 2019/2020

1. INTRODUCTION In 2010 worldwide, 7.6 million children less than 5 years old died, predominantly due to infectious causes including sepsis; neonatal deaths (in the first 28 days of life), accounted for 40% of the total lives lost 1. In 1990, both the United Nations (UN) and World Health Organization (WHO), prioritized a 2/3rd reduction in the unacceptable child mortality rate by 2015. However, in 2013, 44% of deaths in children under the age of five occurred during the neonatal period, up from 37% in 1990. Despite major advances in neonatal care and increasing research, in developed countries, four of every ten infants with sepsis die or experience major disability including significant permanent neurodevelopmental impairment.2 Prematurely born neonates experience the highest incidence and mortality of sepsis among all age groups

3â&#x20AC;&#x201C;8

. In the United States, a staggering 36% of neonates born before 28 weeks completed

gestation suffer at least one episode of blood stream infection (BSI) during their birth hospitalization with up to a 50% associated mortality 3. Compared to term infants, sepsis in preterm infants is up to 1000-fold more common and is associated with higher rates of mortality and life-long neurodevelopmental handicaps

4, 9â&#x20AC;&#x201C;13

. Of note, it is estimated that 11% of the 135 million births

globally occur before 37 weeks competed gestation (preterm), and preterm births have been increasing steadily, especially in developed countries 1, 14. Isolation of microorganisms from body fluids including blood, cerebrospinal fluid and urine are methods of gold standard for diagnosis of neonatal infection. But, microbiological culture is not available before at least 36-48 h.15 So accurate laboratory tests are required to rule out infection and reduce unnecessary antibiotic treatment.16 So hematological parameters and interleukins may be helpful for early diagnosis of neonatal sepsis.17 Many studies have tried to find valid initial reaction of cytokines for early diagnosis of neonatal sepsis. 18 Inflammatory process in sepsis is very complex in terms of biochemical. Based on the results of laboratory and clinical studies, it has been clear that some pro-inflammatory cytokines reach their peak very quick within one to four hours after the onset sepsis.19 Analysis of immunological mediators may contribute to definitive and timely diagnosis of sepsis. Measuring cytokines as markers of sepsis has been taken into consideration in recent years19 and biochemical markers such as CRP, TNF-a and ILs have been evaluated as the main indicators for early detection of neonatal sepsis.20 Cytokines are polypeptide messengers with low molecular weight which are created by macrophages and lymphocytes in response to antigenic stimulations or products of inflammation.19 One of identifying factors of neonatal sepsis is measuring interleukins. So that it is proposed to increase serum levels of interleukins 6, 8 and 10 as a valuable marker for early diagnosis and prediction of sepsis consequences. 19-21

Interleukin-6 (IL-6) is a pleiotropic cytokine expressed by different cells in response to infections.22 Recently, IL-6 has been investigated for its validity in diagnosing neonatal sepsis.23 Since neonatal sepsis is a major cause of mortality and morbidity in infants, and also early detection of neonatal sepsis leads to appropriate treatment and improve neonatal outcomes, this study has systematically reviewed the diagnosis of neonatal sepsis with IL-6. 2. RESEARCH METHODOLOGY 2.2 Search Strategies A comprehensive literature search was conducted in September 1 st to September 25th 2019 using the databases PubMed, EMBASE and Google Scholar databases in order to do a systematic review and find studies including measures for diagnosis of neonatal sepsis by interleukins. We used the keywords “neonatal sepsis”, “interleukin” and “diagnosis” to search the articles. 2.3 Selection Study Inclusion criteria Articles were selected based on the following criteria: 1) Study population is the infants. 2) Neonatal sepsis is confirmed. 3) Interleukins are evaluated for detecting or predicting neonatal sepsis. 4) Articles are in Persian and English language. 5) There is sufficient data from test results. Exclusion criteria To prepare articles appropriate and relevant to the subject, the following articles were excluded: 1) Articles which had reviewed sepsis in adults or animals. 2) Articles which had used other markers than interleukins. 3) The articles that only their abstract was available. 2.4 Data Extraction Data extracted from each selected study. Extracted data from them was drawn in Excel software with following titles: name and family name of authors, year of study, study method, study area, subject group, control group, type of IL, IL measurement time, sensitivity, specificity, positive predictive value, negative predictive value and the results of the investigations. The quality of selected studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. No Questions

Yes

No Unclear

Was the spectrum of patients representative of the patients who will receive the test in practice?

Were selection criteria clearly described?

Is the reference standard and index test short enough to be reasonably sure

Were the same clinical data available when test results were interpreted as 1

that the target condition did not change between the two tests? 4

Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests?

Did the whole sample or a random selection of the sample, receive verification using a reference standard of diagnosis?

Did patients receive the same reference standard regardless of the index test result

Was the reference standard independent of the index test (i.e. the index test did not form part of the reference standard)?

Was the execution of the index test described in sufficient detail to permit replication of the test?

Was the execution of the reference standard described in sufficient detail to permit its replication?

Were the index test results interpreted without knowledge of the results of the reference standard?

Were the reference standard results interpreted without knowledge of the results of the index test?

would be available when the test is used in practice? 13

Were un interpretable/ intermediate test results reported?

Were withdrawals from the study explained?

Quality Assesment of Diagnostic Accuracy Studies (QUADAs)

3. RESULT 3.1 Research findings and Study Selection The search team were applied to all of the search engines and database mention earlier. Titles and abstract were screened and relevant titles were selected.

20 citations identified PubMed, 30 EMBASE and 50 Google Scholar

50 citations excluded based on screening title dan abstract

38 Potentially relevant articles identified for further review 33 citations excluded after full text review

6 articles included were selected for systematic review

3.2 Quality of study

3.3 Global Distribution of Studies Related to IL-6 Most studies related to diagnosis of neonatal sepsis is conducted using IL-6 in India (3 studies, 50%), China (1 study, 16,7%), Iran (1 study, 16,7% , and Greece (1 study 16,7%). 3.4 Articles Related to The Assessment of IL-6 (6 Articles) The searched studies on the relationship of interleukins and diagnosis of neonatal sepsis were different in terms of inclusion criteria of infants, defining the subject group, research methodology, sample size, interleukins boundary limit and interleukins diagnostic value. 6 prospective studies were conducted. The cutoff for IL6 was between 18 and 181 pg/ml. Sensitivity, specificity, positive predictive value and negative predictive value of IL-6 in searched studies were in Table 1.

Author/

Study

year

method

Zhao et al.,

Prospective

Location

China

2015

Subject group

140

infants

susceptible having

infection

Control

Mar

Measurem

Turning

group

ker

ent time

point

infants

without

Sensitivity

Specificity

Positive

Negative

Result

QUAD

predictive

value

score

IL6,

Before and

IL6: 32 pg/ml

IL6: 87.8%

IL6: 79.6%

Diagnostic value of

3 days after

IL8: 54 pg/ml

IL8: 77.6%

IL8: 63.8%

IL6 was more than

IL6,8:

IL8.

71,4%

86.2%

95.83%

87.5%

infection

treatments

(49 infants with

sepsis and 91 with local infection) Sonawane

Prospective

India

40 infants

IL6

et al., 2015

During the

100 pg/ml

92%

93.33%

Il6 level in patient

first 24 h of

with

sepsis

life

increased and itsâ&#x20AC;&#x2122; increase

is rate

depends on sepsis severity El-Sonbaty

Prospective

Greece

et al., 2016

infants

susceptible having

of clinical

sepsis, with

infants

CRP,

without

TNF

infection

IL6

Prospective

India

al., 2016

after

CRP: 12 mg/l

CRP: 91%

CRP: 100%

TNF nd CRP marker

hospitalizat

TNF:

TNF: 83%

TNF: 100%

are

ion

ng/ml

IL6: 100%

IL6: 47%

sepsis

IL1: 100%

IL1: 47%

towards determining

infants

and

IL6:

confirmed

IL1

pg/ml

sepsis by culture Kumar

infants

113/2 16/8

susceptible sepsis

healthy

infants clinical

IL6 and IL1 values

IL6

IL6:

and

pg/ml

CRP

CRP:

and

181

IL6: 80/1 %

IL6: 85/7 %

IL6: 84/6 %

IL6: 81/8 %

IL6

CRP: 61%

CRP: 90.5

CRP: 86.2

CRP: 70.3

biomarker with high

sensitivity and good

3.78

mg/dl

signs

infection al., 2016

India

infants

susceptible having sepsis

40 infants

healthy

specificity

laboratory

Prospective

diagnosis

IL1: 15 pg/ml

with

without

Ganesan et

superior

new

for

sepsis.

IL6

higher

diagnostic

has

value than CRP. IL6,

IL6:

CRP

pg/ml

and

CRP:

hs-

mg/l

51.29 13.49

IL6: 100 %

IL6: 62.86

IL6

CRP: 80%

sensitive marker and

hp-CRP:

CRP:

CRP

90%

65.70%

specific marker for

a a

very very

CRP

hp-CRP:

diagnosis

32.86% Gharehbag hi

2015

al.,

Prospective

Iran

141 preterm infants including: 1)

CRP,

Immediatel

group A, 12 infants with early

IL6

IL6: 18 pg/ml

IL6: 72%

IL6: 55%

neonatal sepsis. 33%

92%

IL6 has fairly good

y after birth

sensitivity

sepsis signs and symptoms based on

and

medium specificity

positive blood culture in first 72 h

cutting

for detecting early

of birth. 2) group B, 24 infants with

umbilical

sepsis

diagnosis of clinical sepsis. 3)

cord

infectious ill infants

after

group C, 61 infants with probable infection and negative blood culture and 4) group D, 44 infants without clinical and laboratory symtoms of infection in first 72 h of live.

and

non-

Sonawane et al., (2015) in a prospective study evaluated the efficiency of IL6 as a primary diagnostic marker of sepsis. 40 infants with risk factors, clinical signs and symptoms of sepsis as the subject group and 40 healthy infants without risk factors of sepsis were studied as the control group. IL6 had 100 pg/ml, 95.83% sensitivity, 87.50% specificity, 92% positive predictive value, 93.33% negative predictive value and 92.50% accuracy. The results showed that IL6 has maximum sensitivity and specificity compared with other septic markers (CRP, Micro-ESR). It was also found that IL-6 level is increased in patients with sepsis and itsâ&#x20AC;&#x2122; increase rate is depended on the severity of sepsis. In a study by Kumar et al. (2016), IL6 with a turning point of 181 pg/ml had sensitivity, specificity, positive predictive value and negative predictive value of 80.1%, 85.7%, 84.6% and 81.8% respectively. Gharehbaghi et al. (2015), in a prospective study reviewed 141 preterm infants at 26-35 weeks in terms of the relation between early sepsis and increasing the levels of CRP and IL6 in plasma of umbilical cord. They reported the turning number of 18 pg/ml, 72% sensitivity and 55% specificity for diagnosis of early sepsis. In comparation, the articles that related IL-6 assessment without positive predictive value and negative predictive value are Zhao et al. (2015), in a prospective study reviewed 140 infants susceptible of having infection (49 infants with sepsis and 91 with Local infection), IL-6 had a turning point of 32 pg/ml had sensitivity, specificity of 87.8%, 79.6%. Ganesan et al. (2016), in a prospective study reviewed 40 infants susceptible of having sepsis, found that the turning point of 51,29 pg/ml had sensitivity, specificity of 100%, 62.86%. El-Sonbaty et al. (2016), in a prospective study reviewed

36 infants susceptible of having clinical sepsis, 48 infants with

confirmed sepsis by culture, they reported the turning number of 16/8 pg/ml had sensitivity, specificity of 100% and 47%. The average values of IL6 in the proposed studies showed that an IL6 above 67 pg/ml has 90% sensitivity and 70% specificity (Table 2). Table 2 The average of IL-6 diagnostic value regarding neonatal sepsis Biomarker

Boundary

Sensitivity

Specificity

Boundary

Sensitivity

Specificity

Average

values

range

range (%)

boundary

sensitivity

specificity

89.27%

69.6%

(pg/ml)

limit IL6

87.8%

79.6%

18-181

100

95.83%

87.5%

pg/ml

16/8

100%

47%

181

80/1%

85.7%

51.29

100%

62.86

72%

55%

72-100%

47-85%

66.38

4. DISCUSSION Neonatal sepsis is a global problem with very important mortality, complications and consequences. Diagnosis of neonatal sepsis may be delayed due to nonspecific symptoms and lack of positive blood culture in the early stages of sepsis. So, unnecessary treatment with antibiotics may be started before confirming sepsis diagnosis. Thus, the cost of treatment will be increased and resistance to antibiotics will also be created early diagnosis of neonatal sepsis is still considered as a major laboratory and medical challenge due to non-specific clinical signs, lack of standard boundary limit values of sepsis markers and difficulty of differentiating it from non-infectious conditions such as respiratory distress syndrome. 24-25 So, a reliable test is required for diagnosis of neonatal sepsis. Because, delay in beginning treatment with antibiotics can lead to early death during the hours of onset of symptoms of infection.26 Despite that blood culture is a gold standard for diagnosis of neonatal sepsis, but, it is not actually helpful in early diagnosis of neonatal sepsis.27 IL-assessment has been approved in recent studies in order to reduce the time of diagnosis and increase the accuracy of diagnostic tests in the early of infection. Increasing cytokines may be created in normal status after childbirth and this can limit the application of cytokines as a diagnostic marker in newborns care section especially immediately after childbirth. Also, there are numerous other variables such as hypoxia, fetal distress, and premature, steroid use before calving and meconium aspiration which increase cytokines levels and limit their application in diagnosis of early neonatal sepsis. Chemokine and pro-inflammatory cytokines are essential for host defense against microbial infection, but, increase of activated proinflammatory mediators can cause harmful results and lead to extensive damages of small blood vessels, dysfunction of multiple organs and death. 28 Several interleukins with different boundary limit, sensitivity and specificity were evaluated for diagnosis of neonatal sepsis. But, neonatal sepsis is still a major challenge in medicine of newborns due to the lack of a standard in the values of boundary limit of interleukins. IL6 is used in most studies for diagnosis of neonatal sepsis. IL6 is a marker that recently has been taken into consideration for early diagnosis of neonatal sepsis. IL6 is created by monocytes, endothelial cells, fibroblasts and lymphocytes T and B and is much more sensitive than CRP. But, it cannot be used for sepsis as a single marker due to itsâ&#x20AC;&#x2122; short half time.25,29 The study results of Buck et al., showed that IL6 level reach itsâ&#x20AC;&#x2122; pick at the time of admission and is non-quantifiable after 24 h. Since IL6 has a vital role in inducing the creation of CRP in liver, there is the hypothesis that this cytokine is identified in the blood in earlier levels of bacterial infection compared with CRP.30 The results of the studies showed that the average of serum level of IL6 in infants with sepsis is higher than healthy infants.31-34 So, IL6 can be applied as an important marker for early neonatal sepsis in neonates care sections.35 Since studies on adults with sepsis have shown that increasing IL6 level is along with higher mortality, it seems that this mediator is important in pathogenesis of sepsis. 36 One advantage of IL6 assessment is that itsâ&#x20AC;&#x2122; level is increased at the onset of infection, while CRP reaches

its’ maximum concentration with delay. IL6 of umbilical cord blood is a better predictor for starting treatment immediately after birth in infants having risk factors of infection before birth compared with CRP. So, increasing concentration of IL6 and CRP is a risk factor of preterm delivery before 32 weeks.37 IL6 has the highest sensitivity (89%) and negative predictive value (91%) at the onset of infection compared with other chemical makers such as TNF and CRP.30 Hu et al., (2015) evaluated the diagnostic value of IL6 for neonatal sepsis using meta-analysis and reviewed 33 studies including 3135 infants. Sensitivity and specificity of IL6 for diagnosis of neonatal sepsis was calculated respectively 79% and 83%.37 Shahkar et al., (2011) conducted a systematic review and evaluated the role of IL6 to predict neonatal sepsis using meta-analysis method. They reviewed 13 studies including 353 infants with sepsis and 691 infants of control group. Sensitivity and specificity of IL6 were respectively 79% and 84%. According to the results of this study, IL6 is a valid marker for prediction of neonatal sepsis and can be applied for sepsis early diagnosis in neonates care units.29 Based on the results of studies, IL6 higher than 68 pg/ml has 85% sensitivity and 80% specificity. IL6 is a valid and primary predictive marker for neonatal infection which is relevant with severity of infection.35 5. CONCLUSION Wide effort has been done in order to find studies related to diagnosis and prediction of neonatal sepsis. The found studies were different in terms of methodology, method, boundary limit of interleukins and diagnostic value of interleukins. The results of the studies showed that IL6 are primary markers for diagnosis of neonatal sepsis. IL6 had 90% sensitivity and 70% specificity. Combination of IL6 with other interleukins and diagnostic markers will have higher sensitivity and specificity due to its’ short half time. Despite primary diagnostic markers of neonatal sepsis, this disease is yet a major challenge in newborn medicine; it may be due to not having standard values of boundary limit of interleukins and high cost of testing. Therefore, it is helpful to conduct extensive studies to identify more interleukins and standardize the values of boundary limit of interleukins in early diagnosis of neonatal sepsis. REFERENCES 1. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, et al. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(9832):2151–61. 2. Brocklehurst P, Farrell B, King A, Juszczak E, Darlow B, Haque K, et al. Treatment of neonatal sepsis with intravenous immune globulin. The New England journal of medicine. 2011;365(13):1201–11. 3. Barton L, Hodgman JE, Pavlova Z. Causes of death in the extremely low birth weight infant. Pediatrics. 1999;103(2):446–51.

4. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC, et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010;126(3):443–56. 5. Martin GS, Mannino DM, Moss M. The effect of age on the development and outcome of adult sepsis. Crit Care Med. 2006;34(1):15–21. 6. Cohen-Wolkowiez M, Moran C, Benjamin DK, Cotten CM, Clark RH, Benjamin DK, Jr, et al. Early and late onset sepsis in late preterm infants. Pediatr Infect Dis J. 2009;28(12):1052– 6. 7. Watson RS, Carcillo JA. Scope and epidemiology of pediatric sepsis. Pediatr Crit Care Med. 2005;6(3 Suppl):S3–5. 8. Girard TD, Opal SM, Ely EW. Insights into severe sepsis in older patients: from epidemiology to evidence-based management. Clin Infect Dis. 2005;40(5):719–27. 9. Haque KN, Khan MA, Kerry S, Stephenson J, Woods G. Pattern of culture-proven neonatal sepsis in a district general hospital in the United Kingdom. Infect Control Hosp Epidemiol. 2004;25(9):759–64. 10. Martinot A, Leclerc F, Cremer R, Leteurtre S, Fourier C, Hue V. Sepsis in neonates and children: definitions, epidemiology, and outcome. Pediatr Emerg Care. 1997;13(4):277–81. 11. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants. N Engl J Med. 2002;347(4):240–7. 12. Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics. 2002;110(2 Pt 1):285–91. 13. Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162–72. 14. Benitz WE. Adjunct laboratory tests in the diagnosis of early-onset neonatal sepsis. Clin Perinatol. 2010;37(2):421–38. 15. Døllner H, Vatten L, Austgulen R. Early diagnostic markers for neonatal sepsis: comparing C-reactive protein, interleukin-6 soluble tumour necrosis factor receptors and soluble adhesion molecules. J Clin Epidemiol 2001;54:1251-7. 16. Noor MK, Shahidullah M, Rahman H, Mutanabbi M. Interleukin- 6: a sensitive parameter for the early detection of neonatal sepsis. Bangabandhu Sheikh Mujib Med Univ J 2009 No 11;1: 1-5. 17. Mehr S, Doyle LW. Cytokines as markers of bacterial sepsis in newborn infants: a review. Pediatr Infect Dis J 2000;19: 879-87.

18. Tavares E, Maldonado R, Ojeda ML, MinË&#x153;ano FJ. Circulating inflammatory mediators durin start of fever in differential diagnosis of gram-negative and gram-positive infections in leukopenic rats. Clin Diagn Lab Immunol 2005;12:1085-93. 12. Horns KM. Neoteric physiologic and immunologic methods for assessing early-onset neonatal sepsis. J Perina neonatal Nurs 2000;13:50-66. 19. Prashant A, Vishwanath P, Kulkarni P, Sathya Narayana P, Gowdara V, Nataraj SM, et al Comparative assessment of cytokines and other inflammatory markers for the early diagnosis of neonatal sepsiseA case control study. PLoS One 2013;8: e68426. 20. Remington JS. Infectious diseases of the fetus and newborn infant. Saunders/Elsevier; 2011. 15. Boskabadi H, Maamouri G, Tavakol Afshari J, Mafinejad S, Hosseini G, Mostafav Toroghi H, et al. Evaluation of serum interleukins-6, 8 and 10 levels as diagnostic markers of neonatal infection and possibility of mortality. Iran J basic Med Sci 2013;16:1232e7. 21. Boskabadi H, Maamouri GA, Ghayour-Mobarhan M, Tavakkol Afshari J, Shakeri MT, Ferns GAA. Early diagnosis of late neonatal sepsis by measuring interleukin 10: a case control study. J Neonatol 2011;25:82e6. 22. Arani MH, Movahedian A, Arani MG, Adinah M, Mosayebi Z. Predictive value of Interleukin-6 (IL6) in term neonates with early sepsis during 2010-2011. Jundishapur J Microbiol 2013;6: e8580. 23. Murray BE. Can antibiotic resistance be controlled? N Engl JMed 1994;330:1229e30. 24. Mally P, Xu J, Hendricks-MunË&#x153;oz KD. Biomarkers for neonatal sepsis: recent developments. Res Rep Neonatol 2014;4:157e68. 25. Ng PC, Li K, Leung TF, Wong RP, Li G, Chui KM, et al. Early prediction of sepsis-induced disseminated intravascular coagulation with interleukin-10, interleukin-6, and RANTES in preterm infants. Clin Chem 2006;52:1181e9. 26. Turner D, Hammerman C, Rudensky B, Schlesinger Y,Schimmel MS. The role of procalcitonin as a predictor of nosocomial sepsis in preterm infants. Acta Paediatr 2006;95:1571e6. 27. Schollin J. Interleukin-8 in neonatal sepsis. Acta Paediatr 2001; 90:961e2. 28. Shahkar L, Keshtkar A, Mirfazeli A, Ahani A, Roshandel G. Therole of IL-6 for predicting neonatal sepsis: a systematic review and meta-analysis. Iran J Pediatr 2011;21:411e7. 29. Buck C, Bundschu J, Gallati H, Bartmann P, Pohlandt F. Interleukin-6: a sensitive parameter for the early diagnosis of neonatal bacterial infection. Pediatrics 1994;93:54e8. 30. Boskabadi H, Maamouri G, Tavakol Afshari J, Mafinejad S,Hosseini G, Mostafavi-Toroghi H, et al. Evaluation of serum interleukins-6, 8 and 10 levels as diagnostic markers of neonatal infection and possibility of mortality. Iran J basic MedSci 2013;16:1232e7.

31. Abdollahi A, Shoar S, Nayyeri F, Shariat M. Diagnostic value of simultaneous measurement of procalcitonin, Interleukin-6 and hs-CRP in prediction of early-onset neonatal sepsis. Mediterr J Hematol Infect Dis 2012;4:e2012028. 32. Maamouri G, Boskabadi H, Tavakkolafshari J, Shakeri M. Evaluation quantities interleukin 6 in diagnosis of neonatal sepsis. Med J Mashad Univ Med Sci 2006;93:253e60. 33. Romagnoli C, Frezza S, Cingolani A, De Luca A, Puopolo M, De Carolis MP, et al. Plasma levels of interleukin-6 and interleukin-10 in preterm neonates evaluated for sepsis. Eur J Pediatr 2001;160:345e50. 34. Dima M, Ilie C, Boia M, Iacob D, Iacob RE, Manea A, et al. Acute phase reactants and cytokines in the evaluation of neonatal sepsis. Jurnalul Pediatrului 2012;15:27e30. 35. Calandra T, Gerain J, Heumann D, Baumgartner JD, Glauser MP. High circulating levels of interleukin-6 in patients with septic shock: evolution during sepsis, prognostic value, and interplay with other cytokines. The Swiss-Dutch J5 Immunoglobulin Study Group. Am J Med 1991;91:23e9. 36. Celik IH, Demirel G, Erdeve O, Dilmen U. Value of different markers in the prompt diagnosis of early-onset neonatal sepsis. Int J Infect Dis 2012;16:e639. 37. Hu J, Du PF, Bei DD. Diagnostic value of interleukin 6 for neonatal sepsis: a Meta analysis. Zhongguo dang dai er ke zazhi 2015;17:1176e82 [Article in Chinese].

Evaluating Guidelines for Treating Coronary Heart Disease in Hospital Emergency Room: A Systematic Review *Az Zachra Sanati Khodijahยน, Farida Aisyahยน, Anis Sofiaยน *azzachras@gmail.com Medical Study Programยน, Faculty of Medicine, Universitas Sebelas Maret, Surakarta

Introduction: The Sample Registration System (SRS) survey that was conducted in Indonesia shows Coronary Heart Disease (CHD) as the highest cause of death in all ages after stroke, which amounted to 12.9% and included as one of medical emergency condition. In matter of second, people with coronary heart disease could facing sudden death composing coronary heart disease as emergency medical condition followed with high prevalence and incidence, high mortality and morbidity, and common risk factor in worldwide resulting management of coronary heart disease in emergency room as first line management is crucial. This initiates a question about how the coronary heart disease patients with emergency conditions were first handled and treated in hospital emergency room and is written in a form of systematic review. The aims of this systematic review is to evaluated recent guideline or Standard Operation Procedure (SOP) of coronary health disease in emergency room and give solution about this related-health issues. Method: This paper used PRISMA-P (Preferred Reporting Items for Systematic Review and MetaAnalysis Protocols) method to improve the quality of reporting. Initial search using online databases (PubMed, Journal of the American College of Cardiology, Journal of Cardiology, and American Journal of Cardiology) and other sources. In total from initial research, reviewers obtain 253 relevant articles which that were retrived, cloistered, and critically appraised and finally shorten to two articles established for this systematic review. Key Findings: From two studied reviewed in this paper, one paper have CTCA as the intervention, the second paper uses LDL-C level, evidence-based therapies, use of cardiac medications,and dyslipidemia as interventions. Conclusions: Coronary heart disease need more specific and accurate management or guideline, recent guideline majority talk about prevention and the most management in real practice still by ACLS.

Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference (PCC EAMSC) 2020 India Scientific Paper

Evaluating Guidelines for Treating Coronary Heart Disease in Hospital Emergency Room: A Systematic Review

By Az Zachra Sanati K

(G0018039)

Farida Aisyah

(G0018071)

Anis Sofia Harjanti

(G0018023

Evaluating Guidelines for Treating Coronary Heart Disease in Hospital Emergency Room: A Systematic Review

Introduction Emergency situation, as defined by Indonesian ministerial regulation, is the clinical state of patient that needs medical treatment as quickly as possible, to save their lives and prevent disability. Emergency department in a hospital plays a major role for emergency management to conduct initial examination of emergency cases, resuscitation, and stabilization (Ministry of Health Republic of Indonesia, 2016). Five years ago, the Sample Registration System (SRS) survey was conducted in Indonesia, showed that Coronary Heart Disease (CHD) was the highest cause of death in all ages after stroke, which amounted to 12.9% and included as one of medical emergency condition (Ministry of Health Republic of Indonesia, 2017). Coronary Heart Disease or CHD (also called CAD and Coronary Artery Disease) defined as a disease in which there is a narrowing or blockage of the coronary arteries, usually caused by artherosclerosis, initial symptoms show chest pain, shortness of breath during exercise, and heart attack (National Cancer Institute, 2019; WHO, 2019). Coronary heart disease are epidemic in India, data show 17% of total death and 26% of adult death in India by 2001-2003 are contributed by coronary heart disease which increased to 23% of total and 32% of adult death in 2010 (Rajeev et al, 2016). All over, coronary heart disease led to 17.5 million death in 2012 and more than 75% of these death occurred in developing countries, contribute 25-30% of all cardiovascular death and approximately 70,000-90,000 individuals died each years (Rajeev et al, 2016; Thomas et al, 2006). Supplementary, study by Fabian (2016) has recently reported 15.5 million person >20 of age in USA have CHD making CHD as leading cause of death in adults in the US with every individuals have lifetime risk of developing CHD with 2 or more major risk, 37% for men and 18.3% for women (Fabian et al, 2016). As in Indonesia, CHD are estimated to cause more than 470,000 death annually with hypertension as leading risk factor by 20-25% (Mohammad, 2016). Further, risk factor of CHD including anxiety, loneliness and social isolation, job strain, tobacco cessation, lifestyle, physical inactivity, hypercholesterolemia or metabolic syndrome, genetic, diabetes, and degenerative disease (Rajeev et al, 2016; Nicole et al, 2016).

1 61

Figure 1. Prevalence of CHD in USA (Fabian et al, 2016) Pathophysiology of coronary heart disease begins with artherosclerosis, which actually develops and progresses since younger age before the acute event, artherosclerosis is kind of low inflammatory of tunica intima that are accelerated by coronary heart diseaseâ&#x20AC;&#x2122;s risk factor, this inflammation lead to gradual thickening of deeper layers of coronary artery and ended up with narrow the lumen of the artery to various degrees executing inadequate oxygen and blood supply to myocardium then manifests as coronary heart disease (Chris, 2014; John, 2015).

Figure 2. Pathophysiology of Artherosclerosis which lead to CHD (John,2015) 2 62

Complication of coronary heart disease is various, narrow the lumen of artery will increase blood pressure inside vein and lead to push fluid out of vein into surrounding tissue causing oedema (swelling), if oedema happen in liver prompt heart failure, other complication is irregular heartbeat (arrhythmia) happen because heart isn’t getting enough oxygen making part of heart tissue damage and effecting heartbeat become faster or slower, heart rhythm problems may impair the pumping action of the heart causing heart failure, thicker blood clot, and stroke, more complication is heart attack, occur when coronary artery becomes completely blocked, blockage will stops part of the heart muscle from getting oxygen, if this go on too long, that part of the heart muscle will die and becomes life-threatening so immediate medical attention is needed (Informed Health Independent, 2017). In matter of second, people with coronary heart disease could facing sudden death composing coronary heart disease as emergency medical condition followed with high prevalence and incidence, high mortality and morbidity, and common risk factor in worldwide resulting management of coronary heart disease in emergency room as first line management is crucial, therefore the aims of this systematic review is to evaluated recent guideline or Standard Operation Procedure (SOP) of coronary health disease in emergency room. Materials and Method A systematic review with title “Evaluating Guideline for Treating Coronary Heart Disease in Hospital Emergency Room” conducted between August – September 2019 using PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) method. Database used in this systematic review were PubMed, Journal of the American College of Cardiology, Journal of Cardiology, and American Journal of Cardiology. Keyword used in this systematic review explained in table 1 with inclusion and exclusion criteria are: 1) Articles published between 5 years range; 2) Articles discussed about guideline of coronary heart disease as emergency condition; 3) Articles using English only; 4) Having low risk of bias; and 5) Paper quality from moderate to low, detected CASP (Critical Appraisal Skills Programme). Table 1. Boolean method used for article searching Database PubMed

Boolean (Coronary Heart Disease) AND Emergency AND Guideline

3 63

Journal of the American Management OR Guideline of Coronary Heart Disease in College

Cardiology Emergency

(JACC) Journal of Cardiology (JC)

Management AND Coronary Heart Disease AND Emergency

American

Journal

Cardiology (AJC)

Guideline

AND

Coronary

Heart

Disease

AND

Emergency Medical Response System

Initial search using PubMed with keyword “(Coronary Heart Disease) AND Emergency and Guideline” reviewers obtain 131 articles, using Journal of the American College of Cardiology with keyword “Management OR Guideline of Coronary Heart Disease in Emergency” reviewers obtain 57 articles, using Journal of Cardiology with keyword “Management AND Coronary Heart Disease AND Emergency” reviewers obtain 26 articles, and using American Journal of Cardiology with keyword “Guideline AND Coronary Heart Disease AND Emergency Medical Response System” reviewer obtain 39 articles, in total from initial research reviewers obtain 253 relevant articles, based on duplication 140 articles were excluded and 113 articles were screened based on title making 65 title excluded, then 48 articles were screened based on abstract, resulting 34 articles were excluded and 14 articles were screened based on full text assessment, more after 12 articles were excluded, established 2 articles for this systematic review. For detected risk of bias and quality of paper, reviewers using CASP (Critical Appraisal Skills Programme), critical appraisal performed on 2 articles which have passed the selection of inclusion and exclusion for this systematic review, 2 articles were observational cohort study and randomised controlled trial study (RCT), thus critical appraisal using cohort critical appraisal form and RCT critical appraisal form respectively.

4 64

Figure 3. Flow chart of articles selection Table 2. Critical appraisal for Cohort Study Critical Appraisal Question

Jean et al

Did the study address a clearly focused issue?

Yes

Was the cohort recruited in an acceptable way?

Yes

Was the exposure accurately measured to minimise bias?

Yes

Was the outcome accurately measured to minimise bias?

Yes

Have the authors identified all important confounding factors? Have they take account of the confounding factors in the design and/or analysis?

Canâ&#x20AC;&#x2122;t Tell Yes

Was the follow up of subject complete enough?

Yes

Was the follow up of subject long enough?

Yes

Do you believe the result?

Yes

Can the result be applied to the local population?

Yes

5 65

Table 3. Critical appraisal for randomised controlled trial (RCT) Critical appraisal question

Alasdair et al

Did the trial address a clearly focused issue?

Yes

Was the assignment of patients to treatments randomised?

Yes

Were all of the patients who entered the trial properly accounted for at its

Yes

conclusion? Were patients, health workers and study personnel ‘blind’ to treatment?

Yes

Were the groups similar at the start of the trial?

Yes

Aside from the experimental intervention, were the groups treated equally?

Can’t Tell

Can the results be applied to the local population, or in your context?

Yes

Were all clinically important outcomes considered?

Yes

Result Articles were manually analysis by reviewers, 1st reviewer analysis cohort study articles, 2nd reviewer analysis randomised controlled study (RCT), and 3 rd reviewer reanalysis both articles then summarize articles into sections. Table 4. Result of systematic review Author, Year of

Jean et al, 2018

Publication Title

Use

Alasdair et al

guideline-recommended

The RAPID-CTCA trial (Rapid

management in established coronary Assessment of Potential Ischemic heart disease in the observational DYSIS

Heart Disease with CTCA) – a

II study

multicentre

parallel-group

randomised trial to compare early computerised tomography coronary angiography versus standard care in patients presenting with suspected or

confirmed

acute

coronary

syndrome: study protocol for a randomised controlled trial Study Design

Multinational

observational

DYSIS II; Cohort

6 66

study;

Randomised controlled trial

Date and Location Eight countries in Asia

Trial opened in march 2015 – 30

of Research

Hong Kong

June 2018, and completed by 21

India

December 2018 with 34 United

Indonesia

Kingdom sited participating in April

Philippines

2016 and research conducted across

Singapore

35 hospital site in United Kingdom

South Korea

(UK)

Taiwan

Vietnam

Six countries in Europe -

Belgium

France

Greece

Ireland

Italy

Russia

Four countries in middle east -

Jordan

Lebanon

Saudi Arabia

United Arab Emirates

The patients were enrolled into the studies between 2013 and 2014. Sample

Total 10,661 samples were taken with

Sample were 2500 participant with

different categories to be enrol in the

inclusion criteria were ≥18 years old

study:

with symptoms with suspected ACS

1. Acute

Coronary

(ACS) patients

Syndrome whose were

hospitalized, 3867 patient

with at least one of the following will

included:

abnormalities;

1) History

ECG of

2. Patient with stable Coronary ischemic heart disease; 3) Troponin Heart Disease (CHD), 6794 elevation above the 99th centile of patient, inclusion criteria patient were ≥18 years, stable CHD, and attendance at a single physician outpatient

appointment,

7 67

have

the normal reference range.

had a fasting lipid profile done within previous

12 months,

either while on (Lipid-Lowering Therapy) LLT for â&#x2030;Ľ3 months or while not on any LLT Health Problems

Majority patient with CHD are heavy

Patient with potential ischemic heart

smokers, an ACS patient at first place,

disease and having one of the

overweight,

following inclusion criteria.

myocardial

infection,

unstable angina, chronic kidney disease (CKD), congestive heart failure, stroke, peripheral vascular disease, and suffered from hypertension and diabetes mellitus Intervention(s)/Ma

nagement(s)

26% of ACS patients and 31% of

The intervention is CTCA, CTCA

patient with stable CGD achieve

will

the recommended LDL-C level

radiologist or cardiologist within an

of <70 ml/dL.

established

The

use

delivered

radiology

rained service.

evidence-based

Patient randomised to standard care

therapies was lower in patients

will receive standard management,

with

the only difference will be the early

approximately 1 in 5 patients not

use of CTCA in the intervention arm

taking aspirin and 1 in 10 not

and the subsequent impact on

taking a statin.

patient care after the result provided

The rates of use of cardiac

to the clinician for decision making

stable

disease,

medications were high among patients in the Middle East, whereas lower rates (and lower intensity of statin therapy) were observed in Asia. -

9.3% of patients with stable CHD and 12.9% with an ACS had residual dyslipidemia.

Outcomes

Indicate opportunities for

The primary endpoint will be all-

improvement in the

cause death or recurrent non-fatal

management of patients with

type 1 or type 4b MI at one year and time to first such event.

8 68

CHD in several geographic regions. -

The use of higher doses of statins and/or combination therapy is likely to improve attainment of lipid goals and thus reduce cardiovascular morbidity and mortality.

Residual dyslipidemia may therefore facilitate a reduction in the substantial cardiovascular risk that persists in patients with established CHD

The use of electronic communication and information technology to support remote clinical care could be useful in effecting changes in patient behaviour.

Discussion Basic management of coronary heart disease in emergency room Advanced Cardiac Life Support (ACLS). ACLS based on four CPR (Cardiopulmonary Resuscitation) position: Airway, Circulation, Leader, and Support (Kah et al, 2014). The next step to overcome cardiac arrest emergency is secondary ABCD (Airway, breathing, Circulation, Differential Diagnosis) initially provide rescue breath using an ambu bag and a mask at full flow oxygen and have the person doing chest compressions pause during the 2 rescue breaths (United Medical Education, 2019). Advanced airway with indication health provider unable to open airway using head tilt-chin lift or jaw thrust maneuvers, difficulty

9 69

to forming a seal with face mask, patient required continued ventilator support, and when patient has high risk for aspiration (United Medical Education, 2019). Figure 4. Algorithms of ACSL (United Medical Education, 2019)

Basic Life Support (BLS) of patient with coronary heart disease which lead to heart arrest is procedure that can be done by health background personnel and non-health

10 70

background personnel in first line in emergency room (ER). Emergency room where people need immediate medical attention usually filled with 1-2 or maximum number is 5 general practitioners with high working hour, BLS usually found obstacle where general practitioner getting tired in middle procedure or there is no help around to help doctor with the procedure, in this systematic review we recommended people around the emergency room, such like security guard getting certificate for basic life support, especially for ACLS, this way could make basic life support procedure in ER easier. This recommendation can be entered to any hospital guideline if coronary heart disease. Limitation of this study is lack of journals discussed about guideline or management of coronary heart disease to be reviewed. Conclusion Coronary heart disease, one of emergency medical condition, with high prevalence of mortality and morbidity making coronary heart disease need accurate management or guideline, recent guideline majority talk about prevention and the most management in real practice still by ACLS. ACLS it self found its obstacle where there is limitation of general practitioner, solution for this obstacle is forming emergency team with non-medical background, such like security personnel and medical background personnel to response this emergency condition. Funding This systematic review do not funded by any organization, person, or any third party.

11 71

References Alasdair J. Gary, Carl Roobottom, Jason E. Smith, Steve Goodrace, Katherine Oatey, Rachel Oâ&#x20AC;&#x2122;Brien, Robert F. Storey, Lumine Na, Steff C. Lewis, Praveen Thokala, and David E. Newby. (2016). The RAPID-CTCA trial (Rapid Assessment of Potential Ischemic Heart Disease with CTCA) â&#x20AC;&#x201C; a multicentre parallel-group randomised trial to compare early computerised tomography coronary angiography versus standard care in patients presenting with suspected or confirmed acute coronary syndrome: study protocol for a randomised controlled trial. BioMed Central, 17:579-582. Chris Tanto, Frans Liwang, Sonia Hanifati, and Eka A. Pradipta. (2016). Kapita Selekta Kedokteran II 4th Edition. Faculty of Medicine University of Indonesia: Media Aesculapius. 748-755 pp. Fabian Sanchis-Gomar, Carme Perez-Quilis, Roman Leischik, and Alejandro Lucia. (2016). Epidemiology of coronary heart disease and acute coronary syndrome. Annals of Translational Medicine, 4(13):256-268. Informed Health Independent (2017). Complication of Coronary Artery Disease. Germany: Institute for Quality and Efficiency in Health Care (IQWiG). Jean Ferrieres, Dominik Lautsch, Baishali M. Ambegaonkar, Gaetano M. De Ferrari, Ami Vyas, Carl A. Baxter, Lori D. Bash, Maja Velkovski-Rouyer, Martin Horack, Wael Almahmeed, Fu-Tien Chiang, Kain K. Poh, Moses Elisaf, Philippe Brudi, and Anselm K. Gitt. (2018). Use of guideline-recommended amangement in established coronary heart disease in the observational DYSIS II Study. International Journal of Cardiology, 270(2018):21-27. John A. Ambrose and Manmeet Singh. (2015). Pathophysiology of coronary artery disease leading to acute coronary syndromes. F1000Prime Reports, 7(8). Kah Meng Chong, Eric H. Chou, Chih-Wei Yang, Hui-Chih Wang, Edward P. Huang, YenPin Chen, Jinn-Wei Chen, Yueh-Ping Liu, Wen-Chu Chiang, Patrick C. Ko, and Matthew H. Ma. (2018). Advanced Cardiac Life Support (ACLS) Is All About Airway-Circulation-Leadership-Support (A-C-L-S): A Nover CPR Teamwork Model. Circulation, 130(2):265. Ministry of Health Republic of Indonesia. (2017). Penyakit Jantung Penyebab Kematian Tertunggi, Kemenkes Ingatkan CERDIK. Indonesia Health Department: Jakarta.

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Retrieved

from

depkes:

http://www.depkes.go.id/article/view/17073100005/penyakit-jantung-penyebabkematian-tertinggi-kemenkes-ingatkan-cerdik-.html, accessed on September 2019. Ministry of Health Republic of Indonesia (2016). Peraturan Menteri Kesehatan Republik Indonesia Nomor 19 Tahun 2016 Tentang Sistem Penanggulangan Gawat Darurat Terpadu. Berita Negara Republik Indonesia No.802. Jakarta. Mohammad A. Hussain, Abdullah Al Mamun, Sanne AE Peters, Mark Woodward, and Rachel R. Huxley. (2016). The Burden of Cardiovascular Disease Attributable to Major Modifiable Risk Factors in Indonesia. Journal of Epidemiology, 26(10):515521. National Cancer Institute. (2019). NCI Dictionary of Cancer Terms: Coronary Heart Disease. United State Department of Health and Human Services. Retrieved from National

Cancer

Institute

the

National

Institute

Health:

https://www.cancer.gov/publications/dictionaries/cancer-terms/def/coronaryheart-disease, accessed on September 2019. Nicole K. Valtorta, Mona Kanaan, Simon Gilbody, Sara Ronzi, and Barbara Hanratty. (2016). Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart, 102(13):1009-1016. Rajeev Gupta, Indu Mohan, and Jagat Narula. (2016). Trends in Coronary Heart Disease Epidemiology in India. Annals of Global Health, 82(2):307-315. Thomas Gaziano, K. Srinath Reddy, Fred Paccaud, Sue Horton, and Vivek Chaturvedi. (2006). Cardiovascular Disease: Disease Priorities in Developing Countries, 2nd Edition.

New York: The International Bank for

Reconstruction and

Development/The World Bank. 1-41 pp United Medical Education. (2019). ACLS Algorithms 2019. Retrieved from United Medical Education:

https://www.acls-pals-bls.com/algorithms/acls/,

accessed

September 2019. World Health Organization. (2017). Cardiovascular disease (CVDs). World Health Organization: Facts Sheet. Retrieved from WHO: https://www.who.int/en/newsroom/fact-sheets/detail/cardiovascular-diseases-(cvds), accessed on September 2019.

13 73

ABSTRACT Suicidal Ideation as a Risk Factor of Suicide in Asian Countries for Psychiatric Emergency Screening: A Systematic Review and Meta-Analysis of Case Control Studies Fabiola Cathleen*, Ayers Gilberth Ivano Kalaij, Muhammad Faza Soelaeman, Sarah Latifa Raharja *Fabiola_cathleen@yahoo.com

Introduction: Suicide is the most common psychiatric emergency which rate has increased by 60% in the last 45 years. It is the third cause of death people aged 15-44 causing a high burden in the productive group. WHO data shows that Asia is a prominent region affected by this problem because it contributes two thirds of the total amount of cases. Individual proper identification of suicidal-risk such as knowing suicidal ideation is the preferred way to prevent suicide. Unfortunately, not every emergency department physician screen the high-risk patient for suicidal ideation making it tend to be unrecognized or underestimated.

Objective: To substantiate the link between suicidal ideation and suicide for re-evaluation of pre-existing screening guidelines for high-risk individuals in psychiatric emergency setting.

Materials and method: This review was conducted based on four-phased PRISMA Statements’ flow diagram and checklist. Casecontrol studies were chosen because it induce lesser ethical issue than prospective design. For the systematic review, our inclusion criteria are: case-control studies with sample who have received psychiatric care and aged 15-44 y.o. from legitimate records, while our exclusion are: language, incomplete or inaccessible text, publications older than 2000, participants with interfering medical illnesses. For the meta analysis, only studies with suicidal ideation as an independent risk factor for suicide are included. For bias and quality assessment, Oxford’s Critical Appraisal Skills Programme (CASP) Case Control Checklist and Oxford’s critical appraisal worksheet for systematic review were used towards this review. Analysis was depicted in forest plot and funnel plot using Revman 5.3 Software for Mac.

Results: The searches yielded 641 records and final 6 studies were included in meta-analysis. The most common bias from CASP were acceptability of cases recruitment. Analysis through forest plot has shown a

statitically significant association between suicidal ideation and suicide (OR: 4.20; 95% CI 3.00-5.88; I : 2

0%; p-value<0.00001. Funnel plot assessment is symmetrical.

Discussion: Suicidal ideation is risk factor of suicide and it can be used as an indicator as a predictor of suicide conduct. Individual who reported suicidal ideation is 4.20 times more likely to commit suicide. Studies suggest that suicidal ideation should be added in suicide early screening to prevent someone completes the act. Review limitation includes few included studies and recall bias due to non-standardized and variable quality of case notes entry.

Conclusion: In conclusion, suicidal ideation can be use as a risk factor of suicide conduct in Asian countries. Suicide prevention guidelines should include suicidal ideation assessment as an important emergency management formulation.

Keywords: Suicidal ideation, suicide, Meta-analysis

Suicidal Ideation as a Risk Factor of Suicide in Asian Countries for Psychiatric Emergency Screening: A Systematic Review and Meta-Analysis of Case Control Studies Pre Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2020

Fabiola Cathleen*, Ayers Gilberth Ivano Kalaij, Muhammad Faza Soelaeman, Sarah Latifa Raharja *Fabiola_cathleen@yahoo.com

AMSA-Indonesia Universitas Indonesia

INTRODUCTION

amount of cases, both in high (such as Japan

Rationale

and Korea) or middle-to-lower (such as India and Pakistan) income countries (World Health

Suicide is the most prevalent psychiatric

Organization, 2019). However, few research

emergency, as stated by WHO that in every 40

has been conducted in this region although

seconds, a person dies from committing

several studies suggested a difference in

suicide. The suicide rate has increased by 60%

suicidal properties between Asian and Western

in the last 45 years, making a concerted effort

population,

towards tackling the problem more important

resulting

formulating

than ever before. (Weber et al., 2017; World

accurate

difficulty and

integrated

interventions, covering both preventive and

Health Organization, 2014). It accounts as the

curative measures (Yim et al, 2004).

third-highest cause of death of individuals between 15-44 years old, the most productive

Suicide itself is classified as major psychiatric

age of a person, causing negative impact to the

emergency, as it may result with loss of life if

society (World Health Organization, 2019). A

not given immediate treatment. Therefore, if a

study in the United States have shown that one

suicide risk (implicit or explicit) is identified,

suicide results in the loss of around 1.3 million

the patientâ&#x20AC;&#x2122;s safety followed by suicide risk

USD, with 97% accounting for the loss of

assessment has to be guaranteed (Health

productivity (Suicide Prevention Resource

Europa, 2018). Prevention through proper

Center, 2019). Moreover, a study in Canada describes that in 2014, the amount of Potential

identification

Years of Life Lost (PYLL) per 100,000

remains the preferred and most essential way

population

years

to tackle completion of suicide (Sudarsanan et

(Statistic Canada, 2019). Indonesia, as one of

al., 2004). Recent studies shows suicidal

the Asian region countries, continues to have a

ideation as an emerging potential suicide

problem in suicide rates. In 2018, the country

indicators, which refers to thoughts that life

has ranked 65 in suicide rates with 2.9 suicides

isnâ&#x20AC;&#x2122;t worth living, ranging in intensity from

per 100,000. (Rakhmat, Tarahita, 2018). These

fleeting thoughts through to concrete, well

data suggests the severe implications caused

thought-out plans for killing oneself, or a

by current suicide rate to the society, and the

complete preoccupation with self-destruction

importance of reducing these numbers.

(Head Space National Youth Mental Health

approximately

360

suicidal-risk

individuals

Foundation, 2009). The global average for suicide have reached up to 10.6 per 100,000 population. Among

A study by Bridge JA, et al. shows outstanding

those numbers, the WHO data shows that Asia

result that screening within a high-risk group

is a prominent region affected by this problem,

consisting

contributing to almost two thirds of the total

discharged psychiatric care patient, manages to

inpatient,

outpatient,

decrease suicide attempt by 30% in one year

period (Bridge et al., 2017). Unfortunately,

MATERIAL AND METHODS

only 8-25% emergency department physician

This systematic review and meta-analysis were

screen the high risk patients for suicidal

conducted based on Preferred Reporting Items

ideation, as it is may be unrecognized or

for Systematic Reviews and Meta-Analyses

underestimated (Head Space National Youth

(PRISMA) Statementsâ&#x20AC;&#x2122; flow diagram and

Mental Health Foundation, 2009; Bridge et al.,

checklist in order to improve quality of

2017). This supports the conjecture even more,

reporting. It is a four-phased flow diagram and

where current suicide rates might have resulted

the checklist consists of 27 items pertaining to

from the lack of suicidal ideation assessment

the content of systematic review and meta-

in high-risk group.

analysis,

including

the

title,

abstract,

introduction, methods, results, discussion, and

Objectives

funding (PRISMA, 2015).

Thus, this review is the first systematic review and meta analysis conducted in order to

Study Search

substantiate the effects of suicidal ideation

Multiple

screening

individuals

Cochrane, Science Direct, BMJ, and PLOS

psychiatric care

were explored using several search strategies

history in an asian setting, which desperately

up to 27 September 2019. The search strategy

needs a new effect estimation specific to asian

was structured using the following concept of

population.

keywords, which was modified based on each

among

high-risk

consisting of those with

databaseâ&#x20AC;&#x2122;s

databases

including

terms

and

Pubmed,

conditions,

Through these endeavors, this review is

summarized in Table 1. In the search terms,

anticipated to increase the awareness of

the inclusion criteria case control and asian are

emergency department physician, psychiatric

not included because numerous relevant

care physician, and public on the importance

studies have been previously missed. Case

its

control studies was chosen relying on the fact

implication on suicide completion. Hopefully,

that most available studies of suicide risk

the results of this review can lead to re-

factors use retrospective design due to its

evaluation of pre-existing practical evidence-

minimal ethical issue. Only fully published

based

studies were searched. Additional records were

assessing

suicidal

screening

ideation

with

guidelines for high-risk

individuals in psychiatric emergency setting,

identified

as an integral part of Mental Health Action

bibliographies from other studies not identified

Plan of the World Health Organization

in electronic searches.

(WHO), with the goal of reducing the rate of suicide in countries (Health Europa, 2018).

through

manual

and

Table 1. Summary of Search Terms

Database

Search Terms

PubMed,

((((suicidal ideation[MeSH Terms]) AND (risk OR factor OR association OR relationship OR

Science

correlation OR link OR relation)) AND (suicide OR suicide attempt)) AND asian

Direct Cochrane

((((suicidal ideation) AND (risk OR factor OR association OR relationship OR correlation OR link OR relation)) AND (suicide OR suicide attempt)) AND asian

BMJ

Suicidal ideation (all words) in title and abstract AND suicide (all words) AND asian (all words)

PLOS

((((everything:”suicidal ideation”) AND everything:suicide) AND everything:asian) AND everything:association)

Study Selection

hand as they are inducing lesser ethical issue

The process of study selection followed four-

than prospective design. High-risk patients are

phased PRISMA Statements’ flow diagram,

chosen as sample population since data shows

which are identification, screening, eligibility

that over 90-95% of suicides are committed by

test, and inclusion of studies. From study

people suffering from mental disorders, either

identification using search terms, all duplicates

inpatient, outpatient, or discharged patients

found will be removed. Studies left after

(Sudarsanan et al, 2004).

duplicates removal will be screened based on Table 2. Operational Definition

its titles and abstracts, and those that are not relevant to topic or objectives of this review will be excluded. After screening, all of the

Variable

Definition

Suicidal

Thoughts that life is not worth living,

Ideation

ranging in intensity from fleeting

remaining studies will be assessed for its full-

thoughts through to concrete, well

text

and

thought-out plans for killing oneself,

exclusion criteria. The inclusion and exclusion

or a complete preoccupation with self

eligibility

based

inclusion

destruction (Mythbuster, 2009)

criteria of this study has been discussed and

Suicide

approved by all 4 reviewers.

Intentionally and voluntarily taking one’s life (Merriam Webster)

The inclusion criteria are case-control studies

High Risk

Inpatient, outpatient, or discharged

Individuals

psychiatric care patient (Bridge et al., 2017)

that measure the relationship strength between past suicidal idea and suicide, the usage of high-risk participants, the usage of legitimate

Measures

Includes

legitimate

documented

of suicidal

medical records by physician

ideation

measures of suicidal ideation and suicide, and

Measures

Includes coroner’s verdict, clinical

asian (Table 2). Case control studies is chosen

of suicide

definition, coroner’s court data and national mortality database

due to its availability and accessibility upper

Moreover, the exclusion criteria are language

(CASP) Case Control Checklist was chosen.

besides

English,

This checklist consists of 8 yes-can’t tell-no

incomplete or inaccessible text, publication

questions regarding three broad components,

year older than 2000 and participants with

which are validity, results and application or

possibly-interfering

that

significance of the studies. A number of

cause chronic and intractable pain or limit

italicised prompts are also provided to clarify

patients’ ability to move such as brain

the importance of each question. It was

neoplasm, neurodegenerative diseases, HIV

developed from guides from Evidence Based

infection, epilepsy, etc (Rodzinski et al, 2017).

Medicine Working Group published in the

Studies that are incompatible with inclusion

Journal of the American Medical Association

criteria or follow exclusion criteria were

and has been used since 2006 (Critical

excluded, resulting in studies included in

Appraisal Skills Programme, 2018). This was

qualitative synthesis. Further exclusion is done

done by two reviewers and then checked by a

before studies can be included in meta

third reviewer.

Bahasa

Indonesia

medical

and

illnesses

analysis, focusing on data precision and completeness in each study.

For the assessment of bias across this review, the Oxford’s critical appraisal worksheet for

Data Extraction

systematic review was used. The worksheet

Data were extracted by 1 reviewer using a

contains

standardized format for all studies, then

questions

comprehensiveness,

independently checked and confirmed by 2

assessment

other reviewers. Duplicates have already been

about

eligibility included

focus, criteria,

studies

and

homogeneity of the review to be answered yes,

removed in the prior study selection process,

no or unclear (OCEBM, 2011).

therefore no identical data will be extracted twice. Extraction of study characteristics

Analysis

includes study details (author, publication

In the included studies, there are numerous

year, study design, study population, study location,

measures

suicide,

suicidal

ideation,

statistical

analysis

other risk factors discussed regarding their association to suicide conduct in later years such as race and ethnicity, work-related stress,

method, and result) and participants’ details

family

(sample’s mean age on suicide).

involvement,

employment,

living

condition, however only suicidal ideation that is taken into account. Besides inclusion and

Quality and Bias Assessment

exclusion criteria, only studies that investigate

Quality and bias assessments were done after

suicidal ideation as an independent risk factor

completion of data extraction. For evaluation

for suicide is considered in meta-analysis,

of quality and bias of each included studies,

because combination with other risk factor

Oxford’s Critical Appraisal Skills Programme

could result in analysis bias. Moreover, studies

were included in meta analysis only if they

total records retrieved. Duplicates (n=8) are

reported effect size or other data regarding the

immediately removed, resulting in 633 records

expression

suicidal

to be screened. 609 records were further

ideation among people who later died by

excluded, as they are irrelevant to the topic or

suicide or did not, that enables the calculation

objectives of this review, resulting in 24

of the number of people in true positive group

studies to be assessed for its eligibility. Full

(those with suicidal ideation and suicide), false

text of 1 study can not be retrieved, 3 studies

positive group (those with suicidal ideation but

have incompatible study design and data of the

without suicide), false negative group (those

other 12 studies did not correlate with topic.

without suicidal ideation but with suicide) or

With exclusion of 16 studies, there were 8

true negative group (those without suicidal

studies to be included in the qualitative

ideation or suicide).

synthesis.

nonexpression

The pooled size of control, exposed, positive and negative outcome groups, or the OR, then

Further exclusion were done before meta-

tabulated and analysed into a forest plot using

analysis to 2 studies which are study by

Review Manager 5.3 Software for Mac. Fixed

Funahashi T, et al. and Kan CK, et al.

effect meta-analysis was chosen because of the

Funahashi T, et al did not specify the number

rather similar population and method used in

of positive and negative outcome group,

primary

Between-study

therefore impossible to calculate the effect

heterogeneity was examined using I . To

size. Meanwhile, Kan CK, et al was excluded

estimate the effect from individual studies

because suicidal ideation was not measured as

against measure of each study’s size or

an independent factor to suicide but combined

precision and to assess publication bias, this

with attempted deliberate self-harm. With that,

meta-analysis used funnel plots, also generated

there is a total of 6 studies eligible to be

by Review Manager 5.3 Software for Mac.

included in meta-analysis. The summary of

research.

study search and selection is depicted in accordance

RESULTS

the

four-phase

PRISMA

Statements’ flow diagram in Figure 1.

Initially, searches identified 571 total records from database searching, which are 167, 16,

The summary of risk of bias and quality

168, 21 and 199 from PubMed, Cochrane,

assessment results for each study using the

Science Direct, BMJ and PLOS respectively.

Oxford’s CASP for Case Control Checklist is

The additional records were identified from

depicted in Figure 2 and the elucidation can be

manual search (n=5) and bibliographies from

found in Supplementary 1. Overall result

other studies not identified in electronic

suggests that all studies have minimum 6/9

searches (n=65). Combined, there were 641

“yes” record and 50% of included studies have

recruitment,

sample

number,

and

power

calculation, but both studies still provide precisely defined cases group. However, compared to Funahashi T, et al., Khanra S, et al. only included 10 cases in addition to not giving sample number calculation and this is considered too little of a sample population without explained strong underlying basis, thus a “no” record in Khanra S, et al. and a “can’t tell” record in Funahashi T, et al. Table 3 portrays the characteristics of 8 studies with a total of 1,321 participants included in this review. All study uses case-control study design, either matched or not matched. 6

Figure 1. Study Search and Selection Process

studies were included in the meta-analysis. In these studies, the definition of suicidal ideation were all identically measured by documented medical records by physician. Meanwhile, the definition of suicide ranged from coroner’s verdict, clinical definition, coroner’s court data and national mortality database, which all are official and legitimate in nature, thus still are considered in meta-analysis. The highest Odds Ratio came from Thong JY, et al. (OR=7.99) and the lowest OR of 1,88 Figure 2. Bias and Quality Assessment of Included

came from Kan CK, et al. Besides that, 50% of

Studies with Oxford’s CASP

included studies shows similar mean age of suicide in the 30s, 37.5% studies in the 40s

9/9 “yes” record, implicating low risk of bias

and 12,5% in the 20s. Moreover, the location

and high validity. The most prevalent bias

of the studies varied from Hong Kong (being

from

the individual studies came from

the most studied), Japan, India, China, Taiwan

Question 3 regarding acceptability of cases

and Singapore. This is beneficial because these

recruitment, whereas two studies by Funahashi

included studies were able to represent high,

T, et al. and Khanra S, et al. showed absence

middle, and low income countries in Asia. To

of established reliable system for cases

add, the median age of suicide in all included

Table 3. Summary of Study Characteristics No.

Author and Public ation Year

Study Design

Dong JYS, et al. 200518

Casecontrol

Funahas hi T, et al. 200119

Casecontrol

Kan CK, et al. 200720

Casecontrol

Khanra S, et al. 201621

Casecontrol

Li J, et al. 200822

Casecontrol

Lin SK, et al. 201423

Casecontrol

Thong JY, et al. 200824

Casecontrol

Yim PH, et al. 20047

Casecontrol

Study Population

92 in-patient suicides and 92 matched control

80 people with schizophrenia and 80 matched controls

97 recently discharged mental health in-patients and 97 matched controls

10 current mental health in-patients and 50 matched controls

64 in-patients with schizophrenia and 64 matched controls

41 current mental health in-patients and 162 controls

123 mental health patients and 123 matched controls

73 recently discharged mental health in-patients and 73 matched controls

Sample s’ Mean Age on Suicide

41.4

36.2 ± 12.1

41.5

Stud y Loca tion

Hong Kong

Japan

Hong Kong

25.5 ± 7.40 India

34.6 years

China

33.5

Taiwa n

male 37.4 and female 39.1.

Singa pore

Hong Kong

Measures of Suicidal Ideation

Measures of Suicide

Documented in medical records by physician

Coroner’s verdicts of suicides and undetermined deaths

Study Inclu ded in Metaanaly sis

4.68 (2.32– 9.44)

Yes

Clinically defined

2.96 (1.63– 5.36)

Coroner’s court data

1.88 (1.04– 3.41)

Clinically defined

6.71 (1.12– 40.07)

Yes

Clinically defined

3,19 (1.203– 9.169)

Yes

Documented in medical records by physician

National mortality database

3.44 (1.65– 7.17)

Yes

Documented in medical records by physician

National mortality database

7.99 (3.41– 18.70)

Yes

Documented in medical records by physician

National mortality database

2.81 (1.39– 5.68)

Yes

Documented in medical records by physician

Figure 3. Forest Plot Analysis of Included Studies

Outcome (p<0,05; CI 95%)

studies ranges from 25.5 to 43 years old,

The assessment of bias risk in this review was

consistent with WHOâ&#x20AC;&#x2122;s data of suicide as the

done with the Oxfordâ&#x20AC;&#x2122;s critical appraisal

third leading cause of death in productive age

worksheet for systematic review. Potential bias

of 15-44 years old.

in this review could come from the lack of unpublished literature searching resulting in 0

Figure 3 shows the forest plot for the

unpublished literature in this review. This

association between suicidal ideation on high-

could result in missed important relevant

risk patients and suicide completion. The

studies, leading to lower quality of evidence of

association found in this meta-analysis from 6

this meta-analysis. However we tried to limit

studies was positive and significant (O=4.20,

this shortfall by increasing literature search in

95% CI 3.00-5.88) with a p-value of <0,00001.

5 major bibliographic databases and reference

Heterogeneity in this study with I statistics

lists from relevant studies, with Bahasa

was 0% across case-control included studies.

Indonesia besides English, as well as using

With Cochran Q, Q/df is <1 (4.40/5= 0.88)

both MESH terms and text words. Another

and the p-value is not significant (0.49)

potential bias could come from recall bias

indicating no heterogeneity. This describes the

within included studies since case-control

homogeneity of this review, which was driven

study design is used. Nevertheless, an effort to

by the identical study design, similarity of

minimize this is by requiring studies to have

population and definitions of suicidal ideation

clear definition and comparison groups to be

and suicide, and consistent result finding.

included in the study.

Moreover, funnel plot assessment of included studies

(Figure

showed

DISCUSSION

symmetrical

appearance proving the homogeneity of this

This review discovered suicidal ideation to be

review of a rather low publication bias.

predictive

suicidal

deaths.

High-risk

individuals consisting of those with psychiatric care history and suicidal ideation are 4.20 times more likely to commit suicide compared to those without suicidal ideation (OR=4.20, 95%CI 3.00-5.88, p<0,00001). The OR of the studies range from 1.88 - 7.99, all of which are higher than 1. Thus, it can be summarized that all studies have shown suicidal ideation as a risk factor to suicide, and none of the studies

Figure 4. Funnel Plot Assessment of Included

has mentioned otherwise (Dong JYS, et al.,

Studies

2005; Funahashi T, et al. 2001; Kan CK, et al. 2007; Khanra S, et al. 2016; Li J, et al. 2008;

Lin SK, et al. 2014; Thong JY, et al. 2008;

preparation for suicide increases (Rodzinski et

Yim

the

al, 2017). This phenomenon has shown that

0%,

suicide is a continous process that is preceeded

PH,

et al.

heterogeneity

2004).

between

Moreover,

studies

are

signifying the homogeneity between included

studies. P value for this meta-analysis is

assessment of suicidal ideation as a preventive

p<0.00001,

and risk assessment in emergency setting

meaning

that

the

result

suicidal

ideation,

thus

justifies

the

statistically significant. The assessment of

(Dong

suicidal ideation may uncover patients to make

emphasizes

their intent known and are amenable to

providers to address suicidal ideation on all

intervention. (Dong JYS, et al. 2005)

suspected patients, as the patients have most

JYS). the

Additionally, necessity

this of

finding

healthcare

likely come in contact with a healthcare This result re-highlights the groundbreaking

worker for at least once before committing

concept of presuicidal syndrome as mental

suicide.

state that directly precede suicide proposed in

However, despite the significance of doing

1953, with narrowing of functioning areas

so, some physicians’ concerns about assessing

(dynamic, situational, perceived values and

such questions have also been raised, due to a

interpersonal),

and

common misconception that questions about

accumulation of aggresion and emotional

suicidal ideaiton can lead patients to have or

tension being the 3 major precursors that

increase thoughts and acts of self-harm (Park

coalesce together in contribution to escalated

et al, 2016). Crawford, et al. reported that

suicidal risk (Sadock et al. 2015, Simmon et

screening for depression with suicidal ideation

al. 2012, Nock et al. 2014). Suicide models

in primary care does not lead to feelings that

further explain the magnitude of suicidal

life is not worth living and suggested that

ideation to suicide conduct as it accrelerates

screening and evaluating suicide risk in

habituation that allows individual to overcome

patients with depression is valuable (Crawford

self-harm protective barriers and provides

et al, 2011)

suicidal

impulsiveness,

ideation,

therefore

inducing

implementation and planning of intentions

On another perspective, studies with the same

(O’Connor et al. 2011, Gollwitzer P.M.

topic have also been found outside Asia.

1999).

Evidently, similar results were also found in studies in western countries, such as studies by

Moreover, psychological autopsies shows that

Powell J, et al. (OR=9.94, 95%CI 5.08–19.45),

two thirds of person committing suicide seeks

Hunt IM, et al. (OR= 2.31, 95%CI 1.24–4.32),

professional help within 6 weeks before their

Kim HM, et al. (OR= 5.80, 95% CI 3.86–

acts. Over a period of time, patients tend to

8.71), Sani G, et al. (OR= 2.14, 95%CI 1.24–

become

their

3.69) and Sinclair JM, et al. (OR= 2.88,

95%CI 1.29–6.47). These studies concurrently

problems,

less

communicative

while

concealed

about efforts

emphasize suicidal ideation as a significant

2014). Since little is known about family’s instruction to

risk factor in high risk populations, both in

deal with suicidal ideation, therefore this study also aims to increase public awareness of suicidal ideation as

Asian and Western population. However, a

significant risk factor, in the hope to promote the

study by Yim PH, et al., which has the highest

formation

weight

intervention.

(24,7%)

this

meta-analysis,

family-based

risk

assessment

and

discovered that ethnicity holds a significant effect towards other suicide risk factors. This

Strength and Limitations

can

The strength of this study includes: usage of a

schizophrenia in the suicides, the lower

structural guideline, low risk of bias in

prevalence

included

seen of

the

predominance

substance

abuse

and

studies,

various

countries

comorbidity, the relatively low proportion of

representation, no study heterogeneity, high

patients living alone and less suicidal intent

study specificity, and symmetrical funnel plot.

expressed in Chinese patients compared to

This review is made based on PRISMA

Americans. Less suicidal intent expression in

Statement to ensure the completion and

Asian population has also been described

comprehensiveness of the study. Oxford’s

before (Chiles et al, 1989). These studies

CASP Case Control Checklist was used as

represent higher difficulty in identification of

quality and bias assessment in included studies

suicidal risk in Asian population, therefore it is

and OCEBM across this review. There are 6

reasonable to take with careful consideration

countries included in systematic review and 5

the individual factors such as ethnicity, in

countries in meta-analysis that come from

order to increase accuracy of suicidal risk

different socioeconomic background, therefore

evaluation in patients.

the result of this review could be generalized to broad populations resided in Asia. All of

With that problem in mind, assessment of

included studies has the minimum scale of 6/9.

suicidal ideation is also applicable to the

As stated above, the result of this study shows

families and relatives of high-risk discharged

p-value <0,0001 and 0% heterogeneity, which

patients is imperative, as other studies confirm

represents a specific and trusted result as it has

that patients’ families is a valuable source of

statistically included enough studies and

information. Within the last 12 months before

enough data varieties. Funnel plot data has

suicide, the spouse was informed about

also proven to be symmetrical.

suicidal intention in 69% cases and a friend

On the other hand, limitation of this systematic

was told in 50% cases (Rodzinski et al, 2017).

review and meta-analysis includes: there might

WHO stated that individual`s closest social circle –

be excluded studies resulted from unpublished

partners, family members, peers, friends and significant others – have the most influence and can be supportive in

records, recall bias due to case-control study

times of crisis, that can be a significant source of social,

design

emotional and financial support, and can buffer the

evaluates past suicidal ideation, and reported

impact of external stressors (World Health Organization,

which

could

only

retrospectively

psychopathology may not be as complete or

with actual intention or plan and passive

accurate as prospective studies.

suicidal ideation without intention or a plan may be clinically valuable as well (Jang et al. 2014 dari park). Moreover, future prospective

CONCLUSION

study with large population may be necessary

In conclusion, high-risk Asian individual with

to confirm this review’ results.

suicidal ideation has 4.2 times increased risk of suicide completion compared to those without suicidal ideation. This occurs mainly

FUNDING

because

This review is not funded by any organization,

suicidal

ideation

accelerates

institution or other third parties.

individual’s habituation to self-harm protective barriers

and

consequently

provides inducing

impulsiveness, planning

ACKNOWLEDGEMENT

and

implementation of intention. The assessment

The authors wish to thank dr. Robby Hertanto,

of suicidal ideation may uncover patient’s

dr. Fadhian Akbar, and Marco Raditya.

intents to allow proper intervention, proving it essential to be done by emergency department,

REFERENCES

psychiatric, and public (families). Moreover, it

1. Weber,

is reasonable to take with careful consideration

N.,

Michail,

M.,

Thompson, A., & Fiedorowicz, J. G.

the individual factors such as ethnicity, in

(2017).

order to increase accuracy of suicidal risk

Psychiatric

Assessing

evaluation in patients. The findings of this

and

emergencies:

managing

suicidal

ideation. Med Clin North Am, 101(3),

review are applicable for reevaluation of pre-

553–571.

existing practical evidence-based screening

doi:

10.1016/j.mcna.2016.12.006

guidelines for high-risk individuals in order to

2. World Health Organization. (2014).

reducing the rate of suicide.

Preventing imperative.

Recommendation on Future Research

suicide:

Retrieved

global from

https://www.who.int/mental_health/sui

Participants can be further categorized into

cide-

subgroups based on the severity of the suicidal

prevention/world_report_2014/en/

ideation, for instance using the C-SSRS, since

3. World Health Organization. (2019).

studies have reported that more severe levels

Mental health: Background of supre.

of ideation with some intent or plan indicated a

Retrieved

greater risk for attempting suicide compared

from

https://www.who.int/mental_health/pr

with less severe ideation with intention or a

evention/suicide/background/en/

plan. Other studies have indicated that the

4. Suicide Prevention Resource Center.

distinction between active suicidal ideation

(2019). Costs of suicide. Retrieved

from

https://www.sprc.org/about-

s/Centres/Midland/Suicidal-

suicide/costs

Ideation.pdf

5. Statistics Canada. (2019). Potential

11. Bridge, J. A., Horowitz, L. M., &

years of life lost, for unintentional

Campo, J. V. (2017). ED-SAFE-Can

injuries and suicides. Retrieved from

Suicide Risk Screening and Brief

https://www150.statcan.gc.ca/t1/tbl1/e

Intervention

n/tv.action?pid=1310036901

Emergency Department Save Lives?.

the

JAMA Psychiatry, 74(6), 555-6.

6. World Health Organization. (2019).

12. Critical Appraisal Skills Programme.

Mental health: Suicide data. Retrieved from

(2018).

https://www.who.int/mental_health/pr

Programme checklist. Retrieved from:

evention/suicide/suicideprevent/en/

https://casp-uk.net/wp-

Critical

Appraisal

Skills

content/uploads/2018/01/CASP-Case-

7. Yim, P. H. W., Yip, P. S. F., Li, R. H. Y., Dunn, E. L. W., Yeung, W. S., &

Control-Study-Checklist-2018.pdf

Miao, Y. K. (2004). Suicide after

13. Oxford Centre for Evidence-Based

discharge from psychiatric inpatient

Medicine

care: a case-control study in hong

Evaluation of the 2011 Oxford Centre

kong. Australian and New Zealand

for

Journal of Psychiatry, 38, 65-72. doi:

(OCEBM)

10.1177/000486740403800103

(Background Document). Retrieved

8. Health

Europa.

(2018).

Suicide

(OCEBM).

(2011).

Evidence-Based Levels

Medicine

Evidence

from

prevention: the role of the emergency

https://www.cebm.net/index.aspx?o=5

department. Retrieved from

653

https://www.healtheuropa.eu/suicide-

Initiated

14. Ting, S. A., Sullivan, A. F., Miller, I.,

prevention-emergency-

Espinola,

department/87503/#ref7.

Camargo,

Sudarsanan, S., Chaudhury, S., Pawar,

Multicenter study of predictors of

A. A., Salujha, S. K., & Srivastava, K.

suicide

(2004).

departments. Acad Emerg Med Off J

Psychiatric

Emergencies.

Medical journal, Armed Forces India, 60(1),

59â&#x20AC;&#x201C;62.

doi:10.1016/S0377-

Australia.

screening

et al. in

H.,

(2012).

emergency

15. Betz, M. E., Sullivan, A. F., Manton, A. P., Espinola, J. A., Miller, I.,

10. Head Space National Youth Mental MythBuster:

A.,

Allen,

Soc Acad Emerg Med, 19(2), 239-43.

1237(04)80162-X Health

A.,

Camargo,

A.,

et al.

(2013).

Foundation.

(2009).

Knowledge, attitudes, and practices of

Suicidal

Ideation.

emergency department providers in

Retrieved

from

the care of suicidal patients. Depress

https://headspace.org.au/assets/Upload

Anxiety, 30(10), 1005-12.

16. International Association of Suicide

psychiatric hospital: A Nested case-

Prevention. (2018). IASP Guidelines

control

for Suicide Prevention. Retrieved from

psychological medicine, 38(6), 571–

:https://www.iasp.info/suicide_guideli

576. doi:10.4103/0253-7176.194914

Indian

journal

23. Thong, J. W., Su, A. H. C., Chan, Y.

nes.php#top 17. World Health Organization. (2018). Preventing

study.

suicide:

H., & Chia, B. H. (2008). Suicide in

community

psychiatric patients: case-control study

engagement toolkit. Retrieved from :

in singapore. Australian and New

https://apps.who.int/iris/bitstream/han

Zealand Journal of Psychiatry, 42:

dle/10665/272860/9789241513791-

509-19. 10.1080/00048670802050553

eng.pdf?ua=1

24. Lin, S. K., Hung, T. M., Liao, Y. T.,

18. Dong, J. Y. S., Ho, T. P., & Kan, C. K.

Lee, W. C., Tsai, S.Y., Chen C. C, et

(2005). A case-control study of 92

al. (2014). Protective and risk factors

cases of in-patient suicides. Journal of

for inpatient suicides: A nested case–

Affective Disorders, 87, 91-99.

control study. Psychiatry Research,

19. Funahashi, T. , Ibuki, Y. , Domon, Y. ,

217(1-2), 54-9.

Nishimura, T. , Akehashi, D. and

25. Rodzinski, P., Rutkowski, K., &

Sugiura, H. (2000). A clinical study on

Ostachowska, A. (2017). Progression

suicide

among

Psychiatry

schizophrenics. and

Neurosciences,

54,

suicidal

Clinical

behavior

173-179.

selected

doi:10.1046/j.1440-

ideation

from

suicidal

perspective

suicidological

models.

Pyschiatr. Pol., 51(3), 515-530

1819.2000.00655.x

26. World Health Organization. (2014).

20. Kan, C. K., Ho, T. P., Dong, J. Y. S, et

Preventing

al. (2007). Risk Factors for suicide in

imperative.

the immediate post-discharge period.

Cataloguing-in-Publication Data.

Soc Psychiat Epidemiol, 42(3), 208-

27. Park, E. H., Hong, N, Jon, D. I., Hong,

214. doi:10.1007/s00127-006-0153-0

suicide: WHO

global Library

H.J., Jung, M.H. (2016). Past suicidal

21. Li, J., Ran, M., Hao, Y., Zhao, Z.,

ideation as an independent risk factor

Guo, Y., Su, J., & Lu, H. (2008),

for suicide behaviours in patients with

Inpatient

depression. International Journal of

suicide

chinese

psychiatric hospital. Suicide and Life‐

Psychiatry

Clinical

Practice.

Threatening Behavior, 38 (4), 449-

doi:10.1080/13651501.2016.1249489 28. Crawford, M. ,Thana, L., Methuen, C.,

455. doi:10.1521/suli.2008.38.4.449 22. Khanra, S., Mahintamani, T., Bose, S.,

Ghosh, P., Stanley, S.V., Ross, J.,

Khess, C. R., Umesh, S., & Ram, D.

Gordon F., Blair, G., Bajaj, P. (2011).

(2016).

Impact of screening for risk of suicide:

Inpatient

suicide

randomised controlled trial. Br J Psychiatry, 198, 379-384 29. Sadock, B. J., Alcott, S. V., & Ruiz, P. (2015). Kaplan & Sadockâ&#x20AC;&#x2122;s synopsis of psychiatric behavioral Sciences/Clinical

Psychiatry.

Philadelphia: Wolters Kluwer. 30. Simmon, R. I., Hales R.E., (2012). The American Psychiatric Publishing Textbook if Suicide Assessment and Management,

2nd

Washington:

American

Edition. Psychiatric

Publishing. 31. Nock, M. K. (2014). Oxford Textbook of

Suicide.

New

York:

Oxford

University Press 32. Oâ&#x20AC;&#x2122;Connor R. C., Platt, S., Gordon, J. (2011). International Handbook of Suicide Prevention. Chichester: John Wiley & Sons 33. Gollwitzer

Implementation

M. intentions.

(1999). Strong

effects of simple plans. Am Psychol, 54(7), 493-503 34. Chiles, J. A., Strosahl, K. D., Ping, Z. Y., Michael, M. C., Hall, K, et al. (1989). Depression, hopelessness, and suicidal behavior in Chinese and American

psychiatric

patients.

American Journal of Psychiatry, 146, 339-344.

ABSTRACT Cervical Spinal Cord Injury Emergency Treatment Comparison between Developed and Developing Country: A Systematic Review *Fandi Hendrawan, Febby Gunawan, Prasista Ariadna, Benedictus *hendrawanfandi4@gmail.com

Introduction

The evidence of CSCI across the world is increasing either in developed countries or developing countries. Nowadays, the world of neurosurgery is already advanced. Many techniques and technologies have been developed to reduce the injury either reduce the possibility of respiration failure, thus give the best outcome. However, in developing countries and low-income countries, there might be a different outcome between developed and developing countries. Objectives

This review is conducted to compare the outcomes of CSCI treatment between developing and developed countries. The results are expected to increase awareness of medical experts and practitioners of the results of procedures carried out in two very different situations with various risk factors that can occur. Materials and method : This review was conducted based on PRISMA Statementâ&#x20AC;&#x2122;s flow diagram and checklist. Literature search in MEDLINE and EBSCO was performed, and studies reporting follow-up changes in American Spinal Injury Association (ASIA) Impairment Scale (AIS) or Frankel or ASIA motor score (AMS) scales or Quality of Life were included in the systematic review. The proportion of patients with at least 1 grade of AIS/Frankel improvement, and point changes in AMS were calculated using random pooled effect analysis. Cohort studies were chosen for the purpose of follow-up. Results

From literature searches conducted in 2 databases and additional searches, 351 records and 13 additional researches were retrieved. The final 15 studies were included with 990 participants from retrospective and prospective cohort studies. Participants are graded with AIS or Frankel and AMS for neurological outcomes in both developed and developing countries group.

Conclusion

Most developed countries have advanced technologies and better healthcare system than developed countries have. Therefore, there are difference outcome between developed and developing countries.

Keywords

: traumatic cervical spinal cord injury, neurosurgery, AIS

Cervical Spinal Cord Injury Emergency Treatment Comparison between Developed and Developing Country: A Systematic Review Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2020

Fandi Hendrawan Febby Gunawan Prasista Ariadna Kusumadewi Benedictus Faculty of Medicine, Public Health, and Nursing Universitas Gadjah Mada Yogyakarta 2019

Cervical Spinal Cord Injury Emergency Treatment Comparison between Developed and Developing Country: A Systematic Review *Fandi Hendrawan, Febby Gunawan, Prasista Ariadna, Benedictus *hendrawanfandi4@gmail.com

al., 2015) The prevalence in the world may

Introduction Spinal cord injury is one of the most

variate. In developed countries like America,

common injury forms due to an accident like fall,

Japan, and Canada, the main cause of CSCI itself

road traffic accident (RTA), fall, recreational or

is RTA in people under the age of 65 while falling

occupational accident. (Haddadi & Yosefzadeh,

is the main cause in people over the age of 65.

2016; Joseph et al., 2015; Löfvenmark et al.,

(Dru et al., 2019; Kreinest et al., 2017; Oichi,

2015; Mathur et al., 2015; Moshi, Sundelin,

Oshima, Okazaki, & Azuma, 2016) Meanwhile.

Sahlen, & Sörlin, 2017) In some countries,

assault is also the main cause of spinal cord

countries, which have lower vehicle-users,

injury. (Moshi, Sundelin, Sahlen, & Sörlin, 2017)

should get a fewer accident involves CSCI.

From 4 forms of spinal cord injury; cervical,

(Kreinest et al., 2017; Löfvenmark et al., 2015)

thoracal, lumbal, and sacral spinal cord injury,

But, fall from a height, usually from the tree, is

cervical

the main cause of CSCI in developing countries

spinal

cord injury is

the

most

developing

Tanzania,

countries

low-income

catastrophic event with the highest rates of

morbidity and mortality.

(Furlan, Craven,

Oceania, India, and southern Asia. (Moshi,

Massicotte, & Fehlings, 2016; Hou et al., 2015)

Sundelin, Sahlen, & Sörlin, 2017) Also, RTA is

According to the level of injury, CSCI is divided

the

into complete injury and incomplete injury.

(Löfvenmark et al., 2015; Mathur et al., 2015;

main

cause

Estonia,

and

Pakistan,

Botswana

Turkey,

and

Iran.

An accident, either with high-energy or

Haddadi & Yosefzadeh, 2016) Meanwhile, in

low-energy (Kreinest et al., 2017; Oichi, Oshima,

better developing country like South Africa,

Okazaki, & Azuma, 2016; Kepler et al., 2015),

different from the others, assault is the main cause

which causes any injury in the cervical level of

of CSC. (Joseph et al., 2015)

the spinal cord are called as cervical spinal cord

In CSCI cases, the primary injury that

injury (CSCI). As the injury in the spinal cord, in

involves the spinal cord may happen in the

the cervical level which controls over the

ligament of the spine, the vertebra, blood vessels,

respiration system, CSCI probably causes the

and axonal junction. (Branche, Ozturk, Ramayya,

respiration failure. (Hou et al., 2015; Kaufman et

McShane, & Schuster, 2018) The location of the

cervical spine itself, which is on the posterior of

around the world without looking at the

the respiration tract, may cause compression in

socioeconomic of a country. Although the

the respiration tract as well. (Hou et al., 2015;

adverse effects of post-surgery may be developed

Kaufman et al., 2015) Otherwise, ischemia and

such as urinary infection and respiratory infection

the accumulation of free radicals are a secondary

(Adeolu et al., 2019; Chua et al., 2018) may

injury which rises the CSCI if the injury is not

occur, in many cases, surgery still gives a better

treated well. (Branche, Ozturk, Ramayya,

outcome than non-surgery treatment. However,

McShane, & Schuster, 2018)

developing

countries

and

low-income

CSCI prevalence in the world is not well

countries, surgery treatment becomes a great

recorded, but the evidence of CSCI across the

burden. (Adeolu et al., 2019; Dru et al., 2019;

world is increasing either in developed countries

Lรถfvenmark et al., 2015; Moshi, Sundelin,

or developing countries. (Dru et al., 2019; Joseph

Sahlen, & Sรถrlin, 2017; Uche, E. O., 2015) Also,

et al., 2015; Kreinest et al., 2017; Lรถfvenmark et

low-income communities that live in developed

al., 2015; Moshi, Sundelin, Sahlen, & Sรถrlin,

countries also get a burden due to the high cost of

2017) As the fatal risk of CSCI, immobilization

surgery treatment of CSCI. (Kreinest et al., 2017;

of the spine is the first treatment when the CSCI

Dru et al., 2019) Also, the technology that

occurs either in pre-hospital or during in the

developing countries have is not advanced. Non-

emergency room. (Kreinest et al., 2017) Then, the

surgery treatment is simple, efficient, quick,

next treatment, surgery either non-surgery

cheap, reliable, and safe. Hence, non-surgery

treatment, must be performed. Also, the

treatment in those countries is an option. (Adeolu

ventilator is needed when the injury causes

et al., 2019; Medress, Arrigo, Hayden Gephart,

respiratory failure. (Kaufman et al., 2015) The

Zygourakis, & Boakye, 2015) Despite the

timing for surgery, however, stays controversy

benefits of non-treatment surgery, the outcome

between neurosurgeons even the surgery is

might not increase the quality of life. Even so,

recommended treatment after immobilization of

many of these countries try to give surgery

the spine. (Aarabi et al., 2017; Furlan, Craven,

treatment in the case of CSCI.

Massicotte, & Fehlings, 2016; Kreinest et al.,

Given this background, a systematic

2016; Nagata et al., 2017; Burke et al., 2018;

review of the available evidence regarding the

Gupta DK, et al., 2015; Jug et al., 2016)

outcome of CSCI surgery treatment in various

Nowadays, the world of neurosurgery is already

countries. Specifically, the objective is to

advanced. Many techniques have been developed

compare the outcome of CSCI treatment between

to reduce the injury either reduce the possibility

developing and developed countries.

of respiration failure, thus give the best outcome. Also, the techniques can be done by any expert

Methods

studies. Additional records were also identified

This systematic review was conducted in

through manual searches.

accordance with Preferred Reporting Items for Systematic

Reviews

and

Meta-Analyses

(PRISMA) guidelines. (Moher, Liberati, Tetzlaff,

Study Selection Studies were included if they met the

& Altman, 2009)

following criteria: 1) reported baseline and follow-up neurological status of patients with

Literature Search A computerized search of the literature

cervical SCI of any neurological level, severity,

using MEDLINE (via Pubmed) and EBSCO was

and mechanism, using at least 1 of the following

performed for cohort studies conducted in the last

measures: American Spinal Injury Association

5 years and written in English language. Using

(ASIA) Impairment Scale (AIS), Frankel scale,

the framework of the PICOT (population,

ASIA motor score (AMS), or quality of life, 2)

intervention, comparison, outcome, time) format,

surgery related to cervical SCI was done within

keywords were selected via review of the

48 hours, 3) had a follow-up duration. The

literature. The preliminary keyword list was then

exclusion criteria were as follows: 1) non-cohort

discussed by a group of authors and consulted to

studies, 2) non-traumatic cervical SCI case, such

our supervisor with experience publishing

as degenerative disease, 3) and studies unrelated

numerous systematic review and meta-analysis

to cervical SCI treatment.

articles. The search strategy was structured using the following concept of keywords: ((cervical OR

Data extraction

neck) AND (spinal cord OR medulla spinalis)

Based on these criteria, each retrieved

AND (injury NOT non traumatic) AND

article was screened for eligibility by 2

(management OR therapy) AND surgery AND

independent reviewers at the title and abstract

cohort). The concept is modified within each

level, and then full-text level if potentially

database boolean terms and conditions. Cohort

relevant. All reviewers were trained to perform

studies were used for this review as time-

the screening by senior authors after several

approach design is more suitable for studies

briefing sessions and standardized pilot searches.

related to follow-up and within long period of

When unavailable online, full-text reports were

time. The literature search was conducted on

requested from corresponding authors via email.

August 30th 2019 and was updated on September

In case of multiple publications on the same

8th 2019. Finally, the â&#x20AC;&#x153;similar articlesâ&#x20AC;? feature of

cohort of patients, only the article containing the

the database was used for all included studies, in

most comprehensive set of data was included. In

order to search for potentially missed relevant

case of disagreement between the 2 reviewers regarding eligibility of a study, consensus was

achieved after reevaluation of the article by a senior author.

Table 1. Flow chart of the study

Results A total of 351 citations were identified from PubMed and EBSCO. The additional

Study Characteristics

records were identified from manual search

The

selected

studies

included

(n=13). From 364 relevant articles were selected

prospective cohort studies and 4 retrospective

for full-text review and were subsequently

cohort studies. In total, 14 studies had reported

obtained and assessed for eligibility. Lastly, a

neurological recovery using AIS or Frankel

total of 15 individual articles fulfilled all of the

scales and 1 study had reported recovery using

criteria and were selected for data extraction.

both AIS and AMS scales. Overall, the included

Figure 1 is a flow diagram describing the study

studies reported follow-up changes in AIS or

selection

Frankel scale and AMS scale for 990 patients.

process

performed

according

Studies were published between 2015 and 2019

PRISMA guidelines.

and recruited patients from 8 countries. The mean

improved to grade C, 9 patients (6,82%)

age of study participants ranged from 19 to 44

improved to grade D, and 2 patients (1,51%)

years. For each study, present characteristics for

improved to grade E. Unfortunately, 7 deaths

which data were extracted are provided the

happened to patients that came with grade A

citations in Table 1.

injury and most patients (67,42%) were not improving (grade A injury). Meanwhile, 14 patients (22,22%) of AIS grade B injury

Risk of Bias Assessment Overall, the methodological quality of

improved 1 grade, 28 patients (44,44%) improved

the included studies implicate low risk of bias and

to grade D, and 6 patients (9,52%) improved to

high validity, with the majority of studies (60%)

grade E. One patient from AIS grade B injury

presenting level I evidence (Table 1.). From 15

died and 14 patients (22,22%) did not improved

included studies, it is identified that only 2 level

by scale. There are 46 patients (73,01%) who

I (13,3%) and 4 level II (27%) studies are

improved 1 grade from AIS grade C and 8

included. Mostly, the main sources of bias

patients (12,7%) improved to grade E. However,

included not accounting for possible prognostic

7 patients (11,11%) did not improve by scale and

factors (not reported AIS/Frankel changes

2 patients died. There are 33 patients (37,93%)

according to baseline severity of injury). The full

from grade D who improved to grade E, while 48

assesment can be seen in Appendix 1.

patients (55,17%) did not improve and 6 patients died. Lastly, there are 140 admittances of patients

Recovery and Severity of Injury in Developed

(94,59%) with AIS grade E without complete

Countries

recovery and 8 deaths happened.

A total of 11 studies reported changes of neurology scale after interventions, mainly by

Recovery and Severity of Injury in Developing

surgery, in AIS/Frankel scale scores for 493

Countries

patients. The results of the random pooled effect

A total of 4 studies reported changes of

analysis for each level are presented in Table 2.

neurology scale after interventions, mainly by

There are 132 patients (26.77%) are admitted in

surgery, in AIS/Frankel scale scores for 497

AIS grade A, 63 patients (12,78%) in AIS grade

patients. The results of the random pooled effect

B, 63 patients (12,78%) in AIS grade C, 87

analysis for each level are presented in Table 2.

patients (17,65%) in AIS grade D and 148

There are 241 patients (48,49%) are admitted in

(30,02%) patients in AIS grade E. Random

AIS grade A, 43 patients (8,65%) in AIS grade B,

pooled effect analysis showed that at least 16

48 patients (9,66%) in AIS grade C, 52 patients

patients (12,12%) from AIS grade A injury

(10,46%) in AIS grade D and 113 (22,74%)

improved 1 grade. There are 9 patients (6,82%)

patients in AIS grade E. Random pooled effect

analysis showed that at least 11 patients (4,56%) from AIS grade A injury improved 1 grade. There are 6 patients (1,21%) improved to grade C, 6

Pre operative Grade A B C D E

Neurological recovery with AIS/AMS/Frankel scales in developed countries Post operative Complete A B C D E Tetraplegia Dead Recovery 89 16 9 9 2 0 7 0 0 14 14 28 6 0 1 0 0 0 7 46 8 0 2 0 0 0 0 48 33 0 6 0 0 0 0 0 140 0 8 0 89 30 30 131 189 0 24 0

Neurological recovery with AIS/AMS/Frankel scales in developing countries Pre operative Post operative Complete Grade A B C D E Tetraplegia Dead Recovery A 193 11 6 6 0 0 25 0 B 2 17 11 8 0 0 5 0 C 0 1 22 3 20 0 2 0 D 0 1 1 19 31 0 0 0 E 0 0 0 0 100 0 0 13 195 30 40 36 151 0 32 13

Total 132 63 63 87 148 493

Total 241 43 48 52 113 497

Table 2. Summary of patiensâ&#x20AC;&#x2122; condition in both countries

patients (1,21%) improved to grade D, 193

25 patients (10,37%) died. Meanwhile, 11

patients (80,08%) did not improve by scale and

patients (25,58%) of AIS

grade B injury improved 1 grade, 8 patients

23 patients (47,92%) did not improve by scale

(18,60%) improved to grade D, and 17 patients

and 2 patients died. There are 31 patients

(39,53%) did not improve. Five patients

(59,61%) from grade D who improved to grade

(11,63%) from AIS grade B injury died and 2

E, while 21 patients (40,38%) did not improve or

patients (4,65%) has reduced grade of injury to

even have lower grade of injury. Lastly, there are

grade A. There are 3 patients (6,25%%) who

100 admittances of patients (88,50%) with AIS

improved 1 grade from AIS grade C and 20

grade E without complete recovery and 13

patients (41,67%) improved to grade E. However,

patients (11,50%) recovered completely.

get an accident. Recent study (Oichi, Oshima, Okazaki, & Azuma, 2016) shows spinal cord

Discussion The current condition of CSCI reports are

stenosis can remain asymptomatic since low-

dominated by the developed countries in America

energy fall occurred. With early decompression

and Europe, while in developing countries, a few

surgery, high-grade AIS can be prevented. For

articles have been reported. Based on the data, as

the

pre-hospital

care,

the

the authors predicted, the outcome of the CSCI

international guidelines of CSCI recommend the

treatment has a significant difference between

first

developed and developing countries with the

stabilization for reducing the compression in

same procedure. Also, different outcome is also

spinal cord followed by the delivery to the nearest

seen between the socioeconomic condition either

facility. (Kreinest et al., 2017) As the education

in developed or developing countries. (Dru et al.,

in developed countries are well enough, most

2019)

people have known the guidelines. Thus, the

treatment

for

cervical

accident

In developed countries, many sufficient

incidence of AIS gradeâ&#x20AC;&#x2122;s conversion increases.

facilities are available including radiograph

(Aarabi et al., 2017; Burke et al., 2018)

facility as a guidance for spinal cord surgery. The

Availability of standby paramedics plays as a

distance between the location of an accident and

keypoint in the pre-hospital treatment. Despite

the nearest well facilitated hospital is not far.

the controversy of steroid usage during delivery,

(Kreinest et al., 2017) Therefore, the delivery

spinal cord compression is well reduced earlier

time from the location to the hospital can be

and able to prevent the complication incidence

effective and fast. In some studies, early surgery

such as trachea obstruction. Moreover, a gentle

treatment in CSCI ends up with better outcome

transportation can reduce any complication from

than the late one. (Burke et al., 2018; Branche,

CSCI. In this case, most high socioeconomic

Ozturk, Ramayya, McShane, & Schuster, 2018;

societies use a helicopter for delivery. Otherwise,

Kreinest et al., 2016; Nagata et al., 2017;

ambulance and car are the second option.

Stevenson et al., 2016; Burke et al., 2018) Even

(Kreinest et al., 2017)

so, the best time for CSCI surgery is still in

In a severe case of CSCI, respiration

controversy. (Furlan, Craven, Massicotte, &

failure is not avoidable when high-energy impact

Fehlings, 2016; Kepler et al., 2015; Mattiassich,

occurs. As the location of phrenic nerve comes

G., et al., 2017; Samuel, A. M., et al., 2015) Well

from C3-C5, the paralysis of diaphragm can

educated societies may play a big role in the CSCI

occur when CSCI involve those segments.

patientsâ&#x20AC;&#x2122;

(Kaufman et al., 2015) Hence, ventilator is

survival

rates.

Moreover,

with

radiography imaging, especially MRI, the high

needed.

grade of AIS can be prevented if a person falls or

countries imitating pre-botzinger area in the

100

Another

method

from

developed

brainstem as the pacemaker of respiratory has

is used frequently than non-surgical treatment.

available recently. Since the pacemaker is located

(Kreinest et al., 2017) Although

superior of the phrenic nerve, the impulse from

provided

with

advanced

the pacemaker will not be delivered to the

technologies, well-informed communities, and

diaphragm when there is a lesion either in the

experts in CSCI case, some CSCI cases will still

radix or the fiber of its nerve. The method is

end up with complications or even death of the

creating a new pacemaker around the C3-C5 of

patient. The most common complications are the

spinal nerves so the impulse can be delivered to

respiratory complications such as pneumonia,

the diaphragm. (Kaufman et al., 2015) However,

lung abscess, pulmonary embolism, and urinary

this new method needs further research. Another

tract infection. (Gupta DK, et al., 2015; Adeolu et

complication may occur when the CSCI is

al., 2019; Jug et al., 2016; Medress, Arrigo,

followed by fracture on the vertebra. Spinal cord

Hayden Gephart, Zygourakis, & Boakye, 2015)

stenosis and obstruction of trachea are the

Whereas the common cause of mortality is the

common forms when vertebra fracture is occured.

failure of respiratory and cardiovascular system

Tracheostomy

preferred

due to late decompression surgery and ventilator

treatment in the case of the trachea obstruction

installation. (Adeolu et al., 2019; Kaufman et al.,

because it causes less damage to the larynx. (Hou

2015;

et al., 2015)

Zygourakis, & Boakye, 2015; Moshi, Sundelin,

has

become

the

Medress,

Arrigo,

Hayden

Gephart,

Sahlen, & Sรถrlin, 2017) Possible factors which

As the compression and stenosis of spinal cord are the most common forms in CSCI cases,

increase

the

chances

respiratory

and

either in developed and developing countries,

cardiovascular failure include imaging, medical

decompression surgery is chosen. Various

stabilization, and other management of injuries.

techniques of decompression are available in both

(Samuel, A. M., et al., 2015) Sometimes, the

types of countries. The compression of spinal

infection can be occured. (Adeolu et al., 2019;

cord usually ends up with palsy, paresis, or

Medress, Arrigo, Hayden Gephart, Zygourakis,

numbness. Thus, decompression surgery may

& Boakye, 2015; Gupta DK, et al., 2015)

prevent or, at least, relieve the aftermaths.

Meanwhile, in developing countries, the

(Aarabi et al., 2017; Adeolu et al., 2019; Kepler

primary cause of mortality of CSCI is respiratory

et al., 2015; Kreinest et al., 2016; Tanaka et al.,

failure. (Lรถfvenmark et al., 2015; Moshi,

2019) With advanced devices in developed

Sundelin, Sahlen, & Sรถrlin, 2017) Usually, the

countries, a significant increase of AIS grade

distance between the location of accidents and the

conversion and decrease of mortality rate are

nearest well facilitated hospital is not near.

seen. Also, trust of community to health experts

(Moshi, Sundelin, Sahlen, & Sรถrlin, 2017) For

play a role in this case. Hence, surgery treatment

example, in Tanzania, near Kilimanjaro region,

101

there is no sufficient facilities for CSCI in the

Due to low education in low-income and

nearest hospital. Therefore, the CSCI patients

developing countries, the knowledge of first aid

must be delivered to another city or country like

for RTA with CSCI or vertebral fracture is not

Nigeria, which also has a limited facilities for

understood well in the society. Instead of

CSCI patients. (Cao, Wu, & Liang, 2019; Moshi,

stabilizing the head or delivering the patient

Sundelin, Sahlen, & Sörlin, 2017) Since the

gently, people who stand nearby the accident

delivery takes more time than it must be, if there

rushly delivers the patient to the nearest hospital.

is a compression or injury in the C3-C5 spinal

(Kreinest et al., 2017) This may increase the

nerves, respiratory failure occurs and eventually

possibility of mortality and aftermath of CSCI

ends up as death. Also, availability of ventilator

due to the compression of the spinal cord is not

device is limited in these countries. (Löfvenmark

treated well. Even if the patient survives,

et al., 2015; Moshi, Sundelin, Sahlen, & Sörlin,

numbness, tetraplegia or paraplegia may occur

2017; Haddadi & Yosefzadeh, 2016)

after the surgery treatment. (Chua et al., 2018; Furlan, Craven, Massicotte, & Fehlings, 2016;

Another reason for the high chance of

Kreinest et al., 2017)

mortality in developing countries is standby paramedic and emergency services. (Moshi,

In Nigeria, the common treatments are

Sundelin, Sahlen, & Sörlin, 2017) The experts

Minerva Jacket, Halter traction, Halo traction,

and paramedics is not distributed well across the

and Skull tong (Gradener-Wells tongs). (Adeolu

country. As the consequences, standy paramedics

et al., 2019) Despite the numerous advantages of

is not available in rural regions. When obstruction

these non invasive treatment, the usage of these

of trachea occurs, air cannot pass the respiratory

instruments must be performed with caution as

tract.

paramedics,

the surgeon has little or no control over the

tracheostomy cannot be performed. Therefore,

cervical vertebrae. Thus, over-distracion, tong

hypoxia and hypercarbia occurs and ends up as

pull-out, increasing pain,worsened neurologic

ischemia of the brain which is irreversible and

deficits, skull penetration, tong-site sepsis,

leads to death. (Cao, Wu, & Liang, 2019; Chua et

osteomyelitis, and penetrating brain injury with

al., 2018; Mathur et al., 2015; Stevenson et al.,

extradural, subdural, or intracerebral haematoma

2016) In spite of the fact that the patient survives,

can occur during and after the treatments.

the patient’s quality of life cannot be changed

(Adeolu et al., 2019) However, in Nigeria and

anymore. Late installation of a ventilator device

Cambodia, the government promotes a surgical

also causes irreversible respiratory system.

treatment to increase the patient’s quality of life

Hence, the patient cannot achieve a normal

and decrease the chance of mortality. (Adeolu et

function of the respiratory system and his life

al., 2019; Chua et al., 2018) Anterior and

depends on ventilator. (Kaufman et al., 2015)

posterior approach are the most common surgical

Without

experts

and

102

fixation and decompression surgery in these

developing countries is high. If the surgery is

countries. In Nigeria, small quantities of patients

performed, there is a probability of failed surgery.

having improved neurologic status with none

Indeed, to satisfy the patient, reoperation is

patients deteriorated. (Adeolu et al., 2019; Uche,

needed. Hence, the treatment in developing

E. O., 2015) Nevertheless, the incidences of

countries take more cost than it should be. (Dru

failed surgery are still high due to delayed

et al., 2019; Furlan, Craven, Massicotte, &

presentation and commencement of closed

Fehlings, 2016) Therefore, there are difference

traction reduction. In a better income country,

outcome between developed and developing

Cambodia, most patient comes with AIS grade A

countries.

or B due to motor vehicle accidents and workrelated falls. Therefore, surgery treatment is

Recommendation

preferred in this country since the income per

Since the cost for radiology to be

capita is increasing recently. Anterior cervical

available is high, it needs to wait until the

discectomy and fusion is chosen in most cervical

developing countries increase the economic

injury,

facets.

stability in these countries increase. (Dru et al.,

However, reoperation is performed numerous

2019) Non-surgical treatment will be preferred

times in this country. (Chua et al., 2018) It

for now and the future as it is cheap and simple.

indicates that these countries still need an

With disadvantageous of non-surgical treatment,

experienced surgeon for treating CSCI.

the patientâ&#x20AC;&#x2122;s quality of life is at stake. Hence,

including

bilateral

jumped

more research about using non-surgical treatment is needed to arrange a proper guideline. Since it

Conclusion

is a non-invasive treatment, it may have a chance

Most developed countries have advanced

to be used in developing countries.

technologies and better healthcare system than developed countries have. Transporting time of patient to the hospital is the problem in both

Limitation of the Study

countries. (Samuel, A. M., et al., 2015; Kreinest

The limitation of this study that the

et al., 2017) Nevertheless, in most developing

evidences and reports from developed countries

countries, more time is needed to transport the

are still low. Therefore, the comparison is not

patient to the hospital. Radiology imaging is also

well yet. Also, the surgery methods in this study

limited and not preferred in developing countries

are not one type which can give a probability for

whereas

a different outcome between countries.

commercially

preferred

developed countries since radiology imaging is

Acknowledgement

useful as a guidance for surgery. Therefore, the risk of surgery without any guidance in

103

We are grateful to dr. Prattama Santoso Utomo

Branche, M. J., Ozturk, A. K., Ramayya, A.

and dr. Adiguno Suryo Wicaksono from

G., McShane, B. J., & Schuster, J. M.

Universitas Gadjah Mada for the support and

(2018).

constructive comments for this study.

Presentation

Neurologic as

Status

Predictive

Measurement in Success of Closed Disclosure

Reduction in Traumatic Cervical Facet

The article searching for this paper was supported

Fractures. World Neurosurgery, 114,

by University of Gadjah Mada’s website for

e344–e349.

database

https://doi.org/10.1016/j.wneu.2018.0

and

partnership

3.001

(http://ezproxy.ugm.ac.id).

Cao, B.-H., Wu, Z.-M., & Liang, J.-W. Reference

(2019). Risk Factors for Poor Prognosis of Cervical Spinal Cord Injury with

Aarabi, B., Sansur, C. A., Ibrahimi, D. M.,

Subaxial Cervical Spine Fracture-

Simard, J. M., Hersh, D. S., Le, E., … Akhtar-Danesh,

Intramedullary

Lesion

Postoperative

Magnetic

Dislocation After Surgical Treatment:

(2017). Length

A CONSORT Study. Medical Science

Monitor,

Resonance

Chua, M. H., Hong, R., Rydeth, T., Vycheth,

Impairment Scale Grade Conversion

I., Nang, S., Vuthy, D., & Park, K. B.

Following Decompressive Surgery in Spinal

Neurosurgery,

Cord

80(4),

(2018). Spine Trauma as a Component

Injury.

610–620.

Neurosurgery:

World Neurosurgery, 114, 375–380.

Adeolu, A. A., Ukachukwu, A.-E. K.,

https://doi.org/10.1016/j.wneu.2018.0

Adeolu, J. O., Adeleye, A. O., Ogbole,

3.057

G. I., Malomo, A. O., & Shokunbi, M.

Dru, A. B., Reichwage, B., Neal, D., Vaziri,

T. (2019). Clinical outcome of closed

S., Lockney, D. T., Fox, W. C., … Hoh,

reduction of cervical spine injuries in a

D. J. (2019). Race and socioeconomic

cohort of Nigerians. Spinal Cord Series Cases,

Essential

Outcomes Analysis from Cambodia.

https://doi.org/10.1093/neuros/nyw053

and

1970–1975.

https://doi.org/10.12659/MSM.915700

Imaging is a Strong Predictor of ASIA

Cervical

25,

disparity in treatment and outcome of

5(1).

traumatic cervical spinal cord injury

https://doi.org/10.1038/s41394-019-

with fracture: Nationwide Inpatient

0158-z

Sample database, 1998–2009. Spinal

104

Cord. https://doi.org/10.1038/s41393-

Development and validation of a risk

019-0280-6

prediction model for tracheostomy in acute traumatic cervical spinal cord

Fredø, H. L., Rizvi, S. A. M., Rezai, M., Rønning, P., Lied, B., & Helseth, E.

injury

(2016). Complications and long-term

Journal,

outcomes after open surgery for

https://doi.org/10.1007/s00586-014-

traumatic

3731-y

subaxial

cervical

spine

BMC

Surgery,

European

24(5),

Spine

975–984.

Joseph, C., Delcarme, A., Vlok, I., Wahman,

fractures: A consecutive series of 303 patients.

patients.

K., Phillips, J., & Nilsson Wikmar, L.

16(1).

https://doi.org/10.1186/s12893-016-

(2015). Incidence and aetiology of

0172-z

traumatic spinal cord injury in Cape

Furlan, J. C., Craven, B. C., Massicotte, E.

Town, South Africa: A prospective,

M., & Fehlings, M. G. (2016). Early

population-based study. Spinal Cord,

Versus

53(9),

Delayed

Surgical

692–696.

Decompression of Spinal Cord after

https://doi.org/10.1038/sc.2015.51

Traumatic Cervical Spinal Cord Injury:

Jug, M., Kejžar, N., Vesel, M., Al Mawed,

Cost-Utility

Analysis.

Neurosurgery,

88,

S., Dobravec, M., Herman, S., &

World

Bajrovic, F. (2016).

166–174.

Neurological

https://doi.org/10.1016/j.wneu.2015.1

Recovery after Traumatic Cervical

2.072

Spinal Cord Injury is Superior if Surgical

Gupta DK, Vaghani G, Siddiqui S, Sawhney

Decompression

and

C, Singh PK, Kumar A, Kale SS,

Instrumented Fusion are Performed

Sharma BS. Early versus delayed

within 8 h versus 8–24 h after Injury: A

decompression

Single Centre Experience. Global

cervical

spinal

acute cord

subaxial

injury:

Spine Journal, 6(1_suppl), s-0036-

prospective outcome study at a Level I

1582937-s-0036-1582937.

trauma center from India. Asian J

https://doi.org/10.1055/s-0036-

Neurosurg 2015;10:158-65

1582937

Haddadi, K., & Yosefzadeh, F. (n.d.).

Kaufman, M., Elkwood, A., Aboharb, F.,

Epidemiology of Traumatic Spinal

Cece, J., Brown, D., Rezzadeh, K., &

Injury in North of Iran: A Cross-

Jarrahy, R. (2015). Diaphragmatic

Sectional Study. 4.

Reinnervation in Ventilator-Dependent

Hou, Y. F., Lv, Y., Zhou, F., Tian, Y., Ji, H.

Patients with Cervical Spinal Cord

Q., Zhang, Z. S., & Guo, Y. (2015).

Injury and Concomitant Phrenic Nerve

105

Löfvenmark, I., Norrbrink, C., Nilsson-

Lesions Using Simultaneous Nerve Transfers

and

Wikmar,

Implantable

L.,

Hultling,

C.,

Chakandinakira, S., & Hasselberg, M.

Reconstructive Microsurgery, 31(05),

(2015). Traumatic spinal cord injury in

391–395.

Botswana: Characteristics, aetiology

Neurostimulators.

Journal

https://doi.org/10.1055/s-

and mortality. Spinal Cord, 53(2), 150–

0035-1549159

154.

Kepler, C. K., Kong, C., Schroeder, G. D.,

https://doi.org/10.1038/sc.2014.203

Hjelm, N., Sayadipour, A., Vaccaro, A. R., & Anderson, D. G. (2015). Early

Mathur, N., Jain, S., Kumar, N., Srivastava,

outcome and predictors of early

A., Purohit, N., & Patni, A. (2015).

outcome in patients treated surgically

Spinal Cord Injury: Scenario in an

for central cord syndrome. Journal of

Indian State. Spinal Cord, 53(5), 349–

Neurosurgery: Spine, 23(4), 490–494.

352.

https://doi.org/10.3171/2015.1.SPINE

https://doi.org/10.1038/sc.2014.153 Mattiassich, G., Gollwitzer, M., Gaderer, F.,

141013

Blocher, M., Osti, M., Lill, M., …

Kreinest, M, Ludes, L., Türk, A., Grützner, P. A., Biglari, B., & Matschke, S.

Aschauer-Wallner,

(2017). Analysis of prehospital care

Functional Outcomes in Individuals

and emergency room treatment of

Undergoing Very Early (< 5 h) and

patients with acute traumatic spinal

Early

cord injury: A retrospective cohort

Decompression in Traumatic Cervical

study on the implementation of current

Spinal

guidelines. Spinal Cord, 55(1), 16–19.

Neurological Improvement from the

https://doi.org/10.1038/sc.2016.84

Austrian Spinal Cord Injury Study.

Kreinest, Michael, Ludes, L., Biglari, B.,

Journal of Neurotrauma, 34(24), 3362–

(5-24 Cord Injury:

(2017).

Surgical

Analysis

Küffer, M., Türk, A., Grützner, P. A.,

3371.

& Matschke, S. (2016). Influence of

https://doi.org/10.1089/neu.2017.5132

Previous Comorbidities and Common

Medress, Z., Arrigo, R. T., Hayden Gephart,

Complications on Motor Function after

M., Zygourakis, C. C., & Boakye, M.

Early Surgical Treatment of Patients

(2015). Cervical Fracture Stabilization

with Traumatic Spinal Cord Injury.

within 72 Hours of Injury is Associated

Journal of Neurotrauma, 33(24), 2175–

with Decreased Hospitalization Costs

2180.

with

https://doi.org/10.1089/neu.2016.4416

Outcomes in a Propensity Score-

106

Comparable

Perioperative

Matched

Cohort.

M., Webb, M. L., & Grauer, J. N.

Cureus.

https://doi.org/10.7759/cureus.244

(2015). Analysis of Delays to Surgery

Moshi, H., Sundelin, G., Sahlen, K.-G., &

for Cervical Spinal Cord Injuries.

Sörlin, A. (2017). Traumatic spinal

Spine,

40(13),

992–1000.

cord injury in the north-east Tanzania –

https://doi.org/10.1097/BRS.00000000

describing incidence, etiology and

00000883

retrospectively.

Stevenson, C. M., Dargan, D. P., Warnock,

Global Health Action, 10(1), 1355604.

J., Sloan, S., Espey, R., Maguire, S., &

https://doi.org/10.1080/16549716.201

Eames, N. (2016). Traumatic central

7.1355604

cord syndrome: Neurological and

clinical

outcomes

functional outcome at 3 years. Spinal

Nagata, K., Inokuchi, K., Chikuda, H., Ishii, K., Kobayashi, A., Kanai, H., …

Cord,

54(11),

1010–1015.

Miyoshi, K. (2017). Early versus

https://doi.org/10.1038/sc.2016.34

delayed reduction of cervical spine

Tanaka, C., Tagami, T., Kaneko, J., Fukuda,

complete

motor

R., Nakayama, F., Sato, S., …

multicenter

study.

Unemoto, K. (2019). Early versus late

European Spine Journal, 26(4), 1272–

surgery after cervical spinal cord

1276. https://doi.org/10.1007/s00586-

injury: A Japanese nationwide trauma

017-5004-z

database study. Journal of Orthopaedic

dislocation paralysis:

with A

Surgery

Oichi, T., Oshima, Y., Okazaki, R., &

and

Research,

14(1).

Azuma, S. (2016). Preexisting severe

https://doi.org/10.1186/s13018-019-

cervical spinal cord compression is a

1341-4

significant risk factor for severe

Uche, E. O., Nwankwo, O. E., Okorie, E., &

paralysis development in patients with

Nnezianya, I. (2015). Cervical spine

traumatic cervical spinal cord injury

injury: a ten-year multicenter analysis

without bone injury: A retrospective

of evolution of care and risk factors for

cohort study. European Spine Journal,

poor outcome in southeast Nigeria.

25(1),

Nigerian Journal of Clinical Practice,

96–102.

https://doi.org/10.1007/s00586-015-

18(2),

4142-4

https://doi.org/10.4103/1119-

Samuel, A. M., Bohl, D. D., Basques, B. A.,

3077.151042

Diaz-Collado, P. J., Lukasiewicz, A.

107

203–208.

Appendix 1

Title

Authors

Year

Country

Intervention

Outcome

STROBE Score

Surgery (ACDF, ACCF, decompression and/or fusion, ACDF with fusion with and without decompression , ACCF with fusion with and without decompression)

AIS

71,82%

Intramedullary Lesion Length on Postoperative Magnetic Resonance Imaging is a Strong Predictor of ASIA Impairment Scale Grade Conversion Following ASIA Impairment Scale Grade Conversion Following Decompressive Surgery in Cervical Spinal Cord Injury

Aarabi et al

2017

United States of America

Clinical outcome of closed reduction of cervical spine injuries in a cohort of Nigerians

Adeolu, et al.

2019

Nigeria

Closed reduction using Gardener-Wells traction

Frankel

82,73%

Neurologic Status on Presentation as Predictive Measurement in Success of Closed Reduction in Traumatic Cervical Facet Fractures

Branche, et al.

2018

United States of America

Closed reduction surgery

AIS

84,09%

Ultra-Early (<12 Hours) Surgery Correlates With Higher Rate of American Spinal Injury Association Impairment Scale Conversion After Cervical Spinal Cord Injury

Burke, et al.

2018

United States of America

Surgical decompression

AIS

86,82%

Cambodia

Anterior cervical discectomy and fusion, Cervical corpectomy with bone graft, Posterior spinal fusion with interspinous wiring, Posterior spinal fusion with pedicle screw fixation, Laminoplasty

AIS

66,36%

Spine Trauma as a Component of Essential Neurosurgery: An Outcomes Analysis from Cambodia

Chua, et al.

2018

108

Complications and long-term outcomes after open surgery for traumatic subaxial cervical spine fractures: a consecutive series of 303 patients

Fredø, et al.

2016

Norway

Surgical decompression

AIS

89,09%

Early versus delayed decompression in acute subaxial cervical spinal cord injury: A prospective outcome study at a Level I trauma center from India

Gupta, et al.

2015

India

Surgical decompression

AIS

78,18%

Early outcome and predictors of early outcome in patients treated surgically for central cord syndrome

Kepler et al.

2015

United States of America

Laminectomy, discectomy

AIS

86,36%

Influence of Previous Comorbidities and Common Complications on Motor Function after Early Surgical Treatment of Patients with Traumatic Spinal Cord Injury

Kreinest, et al.

2016

Germany

Surgical spinal stabilization and decompression by laminectomy

AIS

59,09%

Slovenia

Spinal cord decompression Disc- or corpectomy Instrumented spinal fusion Skeletal traction using a halo ring Spinal dislocations closed reduction Open reduction

AIS

85,91%

Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 h versus 8–24 h after injury – a single centre experience.

Marko, et al.

2016

109

Functional outcomes in individuals undergoing very early (<5 hours) and early (5‐24 hours) surgical decompression in traumatic cervical spinal cord injury. Analysis of Improvement from the Austrian Spinal Cord Injury Study (ASCIS)Neurological

Mattiassich, et al.

2017

Austria

Surgical decompression

AIS

91,05%

AIS

69,09%

Early versus Delayed Reduction of Cervical Spine Dislocation with Complete Motor Paralysis: a multicenter study

Nagata, et al.

2017

Japan

Analgesia, muscle relaxation, and intubation Plain radiographs replaced by fluoroscopy Surgical reduction with internal fixation of the dislocated cervical spine or external fixation with a Halo-vest device.

Preexisting severe cervical spinal cord compression is a significant risk factor for severe paralysis development in patients with traumatic cervical spinal cord injury without bone injury: a retrospective cohort study

Oichi, et al

2016

Japan

AIS

94,54%

Traumatic Central Cord Syndrome: Neurological and Functional Outcome at 3 Years

Stevenson, et al.

2016

United Kingdom

Anterior cervical discectomy and fusion Posterior instrumentation and decompression

AIS and AMS

59,54%

110

Cervical Spine Injury: A tenâ&#x20AC;?year multicenter analysis of evolution of care and risk factors for poor outcome in southeast Nigeria

Uche, et al.

2019

Nigeria

111

Minerva jacket application Cervical traction with Crutchfield Cervical traction with Gardner-Wells tongs Operative reduction Spinal fusion Laminectomy Hemilaminectomy Posterior spinous process wiring Cervical discectomy

AIS

84,09%

PCC EAMSC INDIA 2020 Emergency Health Care of Refugee: A Systematic Review Farida Aisyah1 1Medical Student, Faculty of Medicine, University of Sebelas Maret [Correspondent Email: faridaaisyah323@gmail.com]

Abstract Introduction History record a major displacement crises, meanwhile nowadays have testified individuals and even families seeking refuge and protection from hostile world condition. Refugees deputize a diverse group of displaced individuals with unique health issues, disease risk, culture background, civilization, and language making refugee find it hard to access health care service while facing a lot of barrier and other people stigma. Aim Evaluating best strategy to overcome the problem of refugee and barrier of health access on refugee perspective. Materials and Method This study conducted using PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) method. For quality of articles used in this study and risk of bias using Critical Appraisal Skills Programme (CASP). Result Using 4 database, total 16,846 articles were obtain then based on criteria of inclusion and exclusion 3 data were used for this systematic review. Articles extracted based on their sample, health problems, intervention, and outcome Conclusion Refugeeâ&#x20AC;&#x2122;s condition included as emergency condition followed by their barrier of difficult to access health care. These situation making us to understand that every individual have to take part on minimalizing refugeeâ&#x20AC;&#x2122;s barrier on health care access and found a strategy to overcome the barrier. Keyword Access, Barrier, Emergency, Health, Refugee

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Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference (PCC EAMSC) 2020 India

Scientific Paper

Emergency Health Care of Refugee: A Systematic Review

By Farida Aisyah

113

(G0018071)

Emergency Health Care of Refugee: A Systematic Review

Introduction Refugee, based on The United Nation Refugee Agency, the Refugee definition is declaratory, while article 1(A)(2) of the 1951 Convention, as amended by its 1967 Protocol, defined refugee as individual who “owing to well-founded fear of being persecuted for reason if race, religion, nationally, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of protection of that country; or who, not having a nationality and being outside country of his former habitual residence, is unable or, owing such fear, is unwilling to return it.” in Africa, Article 1(2) of the 1969 OAU Convention clarify the further definition of refugee to “every person who owing to external aggression, occupation, foreign domination or events seriously disturbing public order in either part or the whole of his country of origin or nationally, is compelled to leave his place of habitual residence in order to seek refuge in other place outside his country origin or nationally.” As final definition of refugee, based on Latin America Conclusion III of the 1984 Cartagena Declaration, refugee is defined as “person who fled their country because their lives, safety, freedom have been threatened by generalised violence, foreign aggression, internal conflicts, massive violation of human rights or other circumstances which have seriously disturbed public order.” (UNHCR, 2019). History record a major displacement crises, meanwhile nowadays have testified individuals and even families seeking refuge and protection from hostile world condition (Jimmy T. Efird and Pollie Bith-Melander, 2018). Refugees deputize a diverse group of displaced individuals with unique health issues, disease risk, culture background, civilization, and language (Jimmy T. Efird and Pollie Bith-Melander, 2018). Based on recent study by Jimmy and Pollie (2018), at latest count nearly 66 million individual have been forcibly displaced from their resident owing to conflict or persecution, with supplementary 10 million living in statelessness, roughly 20 new refugees every minute and half of them are under 18 (Jimmy T. Efird and Pollie Bith-Melander, 2018). On the other hand, based on World Health Organization (WHO) and The Office of the United Nation High Commissioner for Refugees (UNHCR) report approximately 68.5 million individuals worldwide are currently displace with 25.4 million of these people crossing international boundaries in search of protection (World Health Organization, 2019; General Director of World Health Organization, 2019). Prevalence of refugee increased from 16 to 1 114

26 million between 2000 and 2017, and their share of the total number of international migrants increased from 9-10%, Asia hosted the largest refugee population (14.7 million), Africa the second largest hosted by 6.3 million refugee, followed by Europe with 3.5 million refugee, Northern America with 970,000 refugee, Latin America and the Caribbean with 420,000 refugee, and Oceania with 70,000 refugee (United Nations of Population Division, 2017).

Figure 1. Where refugees from the top 5 countries of origin found camp (Nefti-Eboni et al, 2019)

Figure 2. Number of Refugee (UNHCR, 2019)

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Refugee got a lot negative feeling toward them and constant racist attack from recent hostile media headline and sometimes from politician’s comment (Angela Burnett and Michael Peel, 2001). Journalist Zelda Venter (2014) take down a note based on online posting from foreigners whose expressing their fear of taking advantage of limited South African resources, one person commented, “Ethiopian president should take note of this. Don’t send your sick here to be treated, our own people need it more”, other person also commented, “So now we must treat the whole damn word for free????”, unsurprisingly these kind of comment are no longer strange for society (Theresa A. Velcamp, 2016).

Figure 3. Refugee Camp Condition (Abdullah et al, 2017) Baqa’s camp, largest camp of Palestinian refugee camp in Jordan, in total have 186 household units with 99 units include in low quality (poor), 81 units include as medium, and only 6 units include as very good, those household have poor structure and maintenance with average housing unit area is 90m2-150m2, most unit are attached to dwelling, have no ventilation, and the walls suffered from erosion and cracking, these infrastructure followed by inadequate electricity and water system, in addition, Baqa’a camp is vulnerable to earthquakes because of its proximity to the Dead Sea rift valley (Jamal Alnsour and Julia Meaton, 2013). Yet, refugee also facing health care issue such as disease tracing, multidisciplinary response to disease outbreaks, refugee utilization, hematologic genetic disorder, chronic and mental health issues, trauma, injury, sexual and reproductive health, United States with 5% Korean refugee and 15% Cambodians were found to be hepatitis B positive, and 3.4% of refugee found to have tuberculosis, in Spain, 21% refugee from subSaharan Africa were chronic carriers of hepatitis B, 40% of complaint of refugee were skin complaint such as sunburn and insect bite, there were also misuse of substance, dehydration, otitis media, loss appetite, headache, backache, and other orthopaedic injuries, along with refugee in poorer camp, high rates of diabetes, hypertension, and coronary heart disease were found in people from Eastern Europe, refugee also do not meet their psychological needs, depression, anxiety, panic attack, or agoraphobia become their prior

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mental distress, study of Iraqi asylum seekers in London found that these mental distress was more closely linked with poor social support than being far away from family or origin country (Angela Burnett and Michael Peel, 2001; Leigh Daynes, 2016). Communicable disease and its transmission is identic with the word “refugee”, parasitic disease may also be found with 25% of symptoms, not in least, refugee having crowded and poor sanitation condition making an ideal environment for spread of lice and pathogen, such as Borrelia recurrentis, Rickettsia prowazekii, or Bartonella quintana, louse-borne relapsing fever (LBRF), epidemic typhus, and trench fever (Angela Burnett and Michael Peel, 2001; Sally Cutler, 2015). Study by Vanessa (2012) using 187 refugees from 2009-2010 at Darwin Refugee Health Service concluded the most common disease are vitamin D deficiency (23%), hepatitis B carrier status (22%), tuberculosis infection (18%), schistosomiasis (17%), and anaemia (17%) (Vanessa et al, 2012). Other study by Peta (2018) using 291 refugee in refugee health clinic at University Hospital Geelong, were found latent tuberculosis infection (54.6%), vitamin deficiencies (15.8%), hepatitis B (11%), and schistosomiasis (11%) (Peta et al, 2018). Refugee barrier to achieve health care are: 1) Difficulty obtaining medications; 2) History of trauma or torture; 3) Lack of familiarity health care system; 4) Prioritizing of basic need; 5) Limited expertise clinical in refugee care; 6) Anti-immigrant sentiment in areas of resettlement, and etc (Ranit et al, 2017). Refugee’s initial conditions of being driven out of their hometown followed by people’s perspective about them, their own mental pressure, their burden, and difficult access with government system making refugee’s condition as emergency condition. Emergency defined as unforeseen illness or injury, emergency can be defined in two definition: 1) Emergency is urgent clinical condition which could lead to death and disability; 2) Emergency is condition which experienced by almost all people in certain area which results in death simultaneously and in large number, both definition of emergency is on the second count, if health worker get slip by a second patient could have been died, disable, or even disease outbreak (Ministry of Health Indonesia, 2018). Refugee’s condition could lead to massive and simultaneous death this makes researcher nowadays learn what could be done to solve refugee’s condition, especially in medical area, what strategy is the best way to prevent bad sanitation in refugee camp? What could we done for making equality of health in the refugee camp? What should we do to stop transmission malady?. Study related to refugee are still few, making this systematic review

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aim to evaluating best strategy to overcome the problem of refugee and barrier of health access on refugee perspective. Materials and Method A systematic review of Emergency Health Access of Refugee was carried out using the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) method. In order to find relevant journals and articles for this systematic review, studies search were conducted comprehensively and completely using search engine such as Cochrane, PubMed, Journal of Refugee Study, and Google Scholar. Table 1. Search Engine and Boolean Method Search Engine PubMed

Boolean Emergency Health Care in Refugee NOT Immigrant NOT Mental Health

PubMed

Review Articles OR Research Articles OR Case Report OR Mini Review of Emergency Health Care in Refugee NOT Immigrant NOT Mental Health

Google Scholar

Emergency Health Care in Refugee

PubMed

Emergency Health Care of Asian Refugee NOT Immigrant NOT Mental Health

Journal of Refugee Study

Emergency Health Care of Refugee

Cochrane

Emergency AND Refugee AND Health Care

Criteria of inclusion are: 1) Paper published between 2014-2019, within 5 years range; 2) Paper published only in English; 3) Paper discuss about emergency health care of refugee; 4) Paper quality from moderate to high; and 5) Paper have low risk of bias detected by using critical appraisal. Data were extracted by review, from initial search result through database searching, reviewer found 16,847 articles related to keyword in boolean form, then 479 study were identified and 16,368 study were excluded based on title, from abstract screening reviewer obtain 175 articles with 301 articles exclude, other 159 study were excluded too because of duplication, leaf it only 19 study to full-text articles assessed for eligibility, then 16 study were excluded. Eventually, review acquired 3 studies in total to fulfil criteria for this systematic review. To assess the quality and risk of bias of the paper

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used Critical Appraisal Skills Programme, 3 articles which fulfil the criteria of inclusion and exclusion were cross sectional study therefore reviewer using critical appraisal checklist for cross sectional study.

Figure 4. Flow Chart of Data Selection Table 2. Critical Appraisal for Cross Sectional Study of the Articles Appraisal questions Did the study address a clearly focused question/issue? Is

the research method appropriate for

answering the research question? Is the method of selection of the subjects clearly described? Could the way the sample was obtained introduce (selection) bias?

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Hannah et al

Shannon et al

Judith et al

Yes

Was the sample of subject representative with regard to the population to which the findings

Yes

Canâ&#x20AC;&#x2122;t Tell

Yes

will be referred? Was the sample size based on pre-study considerations of statistical power? Was satisfactory response rate achieved? Are the measurements (questionnaires) likely to be valid and reliable? Was the statistical significant assessed? Are confidence intervals given for the main results? Could there be confounding factors that havenâ&#x20AC;&#x2122;t been accounted for? Can the result be applied to your organization?

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Result Table 3. Result of Systematic Review Author

Tittle

[Year] Hannah

Health

et al

provision

[2018]

refugees

Study Design care Cross for sectional in Study

Germany â&#x20AC;&#x201C; one-

Location, Date Germany, between and

2205 May (67%

December

individuals male

Intervention(s)/

Health Problems

Outcome(s)

Strategy(s)

Physical illness (65%) To fulfil the medical Emergency

and and

chronic

diseases

with

details

33% female) in (28%)

need of the refugee, Cologne

outpatient

clinic

city (OPD)

show

emergency

respiratory

year evaluation of

accommodation

complaints (19%), loco- Red Cross (GRC), among

private

and 984 patient

motor apparatus (15%), and the Association doctor,

non-

outpatient

2015

Sample

tract authority, the German useful cooperation

clinic in an urban

contact (51% male neurologic

emergency

and 49% female)

(9.1%),

accommodation.

majority of patient

system (8%), digestive (ASHIP) build new (NGO), and the

were less than 30

system

years

old

system of Statutory Health government circulatory Insurance Physicians (8%),

organization

skin model for immediate Germany

with (9.5%), headache (7.1%), health

service

for

Cross and local

country of origin is back pain and neck pain refugee. Emergency public Western countries Syria.

Balkan (6%), acute infection of accommodation and the

upper

tracts

respiratory outpatient

(5%),

8 121

health.

However, clinic need

for

the low-

and (OPD) was based on threshold medical

remaining 7% is mental need and barrier of problems,

Red

care for refugees

pregnancies, health care of refugee in all municipal

medical expert reports, in

Germany.

and vaccination. Further, intention

The facilities

admitted suffered from low-threshold infection of the upper

and also

facility

respiratory tract, cough primary and sneezing.

avoid

cost

care

of and

on social

service

and billing by local

emergencies

and unnecessary calls to

be met by OPD,

accessible treatment

health

these single city cannot

83% of children being model was to have a acute physical complaint, easily

doctor should be addressed.

city emergency

service. Shannon

Health

et al

access

[2016]

service Cross and sectional

Jordan, 2014

June 1,634 households

Health

seeking

and To

were

approached service

utilization among study

participated reported

Syrian refugees in

nevertheless

Jordan

(2.9%) were not at (21.5%), chronic medical cash home,

infection

in Jordan some health Syrian refugee by assistance

and

to were

agencies for

non- facilitate access to predictable costs diseases

health service. Other such as antenatal

already (21.2%), injuries (9.7%) recommend

interview for this report,

disease agencies are piloting health

and

household (1.4%) communicable were

health Initially use of

utilization care of Syrian refugee piloting cash for

47 communicable 14 condition

achieve

care, delivery, and

and dental care (8.0%), intervention state in postnatal.

23 likewise

13.9%

of this

study

are Providing health

household (1.4%) household did not seek increasing co-pay for care for Syrian

9 122

declined

interviewed, final included households Syrian (with

be medical

care

because public service and a

the financial issue (64.5%), shift

sample other reason included not 1,550 being of (6.5%),

sick

enough private

not

knowing services,

9,580 provider

inadequate

members).

and equipment (5.3%), disease

sector

and

Health.

moving solution state in

and

traditional

study

not

implemented yet,

other

although

those

hospital solution lead to

transport service to the primary prosper

difficulties (4.1%)

The

changing recommended

medication non-communicable

long wait of appointment

the Jordanâ&#x20AC;&#x2122;s Ministry

having more resources for

household

(5,3%)

toward burden

utilization

refugee where to go (5.9%), focus

refugee is a large

for

care level, creating refugee and also refugee-focused

reduce strain and

services and a strong financial health

promotion on

the

program emphasizing system,

burden health freeing

prevention and more resources

self-care and home commit

management illness.

prioritizing equitable provision of care

10 123

between

refugee

and host country. Judith

Barriers to health Cross

Austria, between 515 refugee (54% Barrier of refugee from Using

et al

care access and sectional

2015 and 2016

[2019]

survey

by Two out of ten

Syrian, 16% Iraqi, getting health care are ATHIS

(Austrian male followed by

service utilization study

23% Afghan, and financial barrier related Health

Interview four out of ten

refugees

other to direct and hidden cost, Survey),

social female

refugee

Austria: Evidence

citizenship), aged lack of accessibility and survey in physical reported do not

from

18-61 years old, transportation, lack of

cross-

sectional survey

consist

and mental health,

met health care,

assessment and support need for care and/or

based on survey

females and 447 for males,

mental

also concern.

health support, and health women

Furthermore, determinants

arriving in Austria knowledge

gaps

in fall 2015 and inadequate

information and physical activity.

early 2016.

flows

between

and drug

like afghan

may result

sustained

124

carried

out

often

reported

unmet

show

23%

descriptive females and 20%

unfamiliarity analyses. Multivariate analyses

male

reported

time

for

health reveal that age and consultation to be

literacy and experiences,

consumption most

in using

with health care service, insufficient

nationals

health Analysis of survey need. Time factor

provider and refugees, were which

and

nationality

largely impossible

limited availability of specify perception of

timewise,

specialized health care good health, refugees

waiting

long list

centre,

barrier

aged 40-59 less often become problem

language and availability perceive their health by 19% of women of interpreters, barrier of as good compared to and 15% of men, strong

socio-culture those in their twenties

stigmatization of refugee. In

percentage,

or thirties. Refugee knowledge as well

22% from

refugee are waiting for

insufficient

Iran,

their health being cured Yemen

Afghanistan, as Jordan, less

language

and become majority often barrier.

Cross

on its own, 21% refugee perceive their health sectional study of do not have time for as good than Syrian.

refugee in Austria

medical check up, 16% Estimated

show

refugee

outcome,

include

in coefficients for Iraqis

interesting where

waiting list, 12% refugee indicate worse health there is just small do not know good doctor, than and 11% refugee cannot understand

Syrians

yet

amount of refugee

coefficients are not

(7% male and 0%

langue significant.

female) indicated

therefore cannot explain

lack of trust in

what the problem is.

Austrian

health

care provider as a sense

for

not

utilizing a health service.

12 125

Discussion Refugee with a lot of obstacle from their country of origin and looking for another hope from other country meet its barrier. Health care access for refugee still included as unaccessible and emergency condition, strategy for minimalizing these barrier should be applied as fast as possible. Barrier of health care access of refugee such as: Language Bosnian, Iraqi, and Somali refugee in United States said, “if we didn’t have someone who spoke our language, I can’t imagine how difficult life would have been” those state explain why language are important in order to access health care. People of Rohingya, Muslim group with 2% of Myanmar population moreover facing poor infant, malnutrition, waterborne illness, and lack of obstetric care, found language as barrier too, Rohingya people speak native Rohingya language while Myanmar majority speak Burmese (Syed et al, 2017; Altaf, 2015). Transportation Transportation is crucial in emergency situation yet refugee have to face this barrier, example of Greece’s refugee camp and the nearest hospital is 6-8 hours driving (Jules, 2016). Data from 103 Syrian refugee conclude 60.2% refugee found hard to access health because long distance to health facilities and 42% refugee found hard to access multiple location for tests or doctors (Merve et al, 2016). Financial/Cost The United Nations (UN) covers 75% of hospital cost for life saving, obstetric, and emergency care but refugee cannot scrape together their 25% and the funding shortfall in Lebanon making UN has only 17% of their initial numbers, estimated was needed for healthcare and cannot even subsidise life saving, emergency, and obstetric care, by October 2014, 10,000 refugee in Lebanon will not have access to life saving emergency healthcare, instead these barrier followed by Lebanon’s health system which private, expensive, and riddled with corruption (Jonathan, 2015). Three barrier above are the most barrier experience by refugee worldwide followed by socio-economic status, knowledge of health, psycho-traumatisation, culturally different concept about illness, and etc. Emergency condition in refugee making this kind of barrier should be minimalize as much as it can and strategy to overcome refugee’s barrier should

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be implemented as fast as possible. Limitation of this study is only used 3 articles because journal about refugee still few and there is only one author so risk of human error high. Conclusion Refugee being in state of emergency while facing a lot of barrier, such as financial/cost, transportation, language, socio-economy, and negative stigma about them. Refugee found it hard too to access health care service, in other hand disease transmission going so fast in refugee camp followed by low sanitation. These situation making us to understand that every individual have to take part on minimalizing refugee’s barrier on health care access and found a strategy to overcome the barrier. Recommendation There is still need for further research about emergency health care of refugee especially in Asia region. Funding This systematic review does not receive any funding by institution, organization, or other third party. References Abdullah S. Terkawi, Basil Bakri, Amena S. Alsadek, Rawaa H. Alsibaee, Esraa M. Alasfar, Amna H. Albakour, Abdulhannan Y. Aljouja, Nour A. Alshaikhwais, Feras A Fares, Pamela D. Flood, Hussam Jnaid, Amina A. Najib, Diaa A. Saloom, Noran A. Zahra, and Khalid A. Altirkawi. Women’s health in Northwestern Syria: Findings from Healthy-Syria 2017 study. Avicenna Journal Medicine, 9(3):94-106. Altaf Saadi, Barbara E. Bond, Sanja Percac-Lima. (2015). Bosnian, Iraqi, and Somali Refugee Women Speak: A Comparative Qualitative Study of Refugee Health Beliefs on Preventive Health and Breast Cancer Screening. Women’s Health Issues, 25(5):501-508. Angel Burnett and Michael Peel. (2001). Asylum seekers and refugees in Britain: Health needs of asylum seekers and refugees. British Medical Journal, 322(7):544-547. Director-General of World Health Organization. (2019). Promoting the health of refugees and migrants: Draft global action plan, 2019-2023. United State of America: World Health Organization.

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Hannah S. Borgschulte, Gerhard A. Wiesmuller, Anne Bunte, and Florian Neuhann. (2018). Health care provision for refugees in Germany â&#x20AC;&#x201C; one-year evalution of an outpatient clinic in an urban emergency accomonation. BioMedicine Health Services Researches, 18(488):1-10. Jamal Alnsour and Julia Meaton. (2013). Housing conditions in Palestinian refugee camps, Jordan. Elsevier, 36(2014):65-73. Jimmy T. Efird and Pollie Bith-Melander. (2018). Refugee Health: An Ongoing Commitment and Challenge. International Journal of Environmental Research and Public Health, 15:131-134. Jonathan Gornall. (2015). Healthcare for Syrian refugees. The British Medical Journal, 351:1-2. Judith Kohnlenberger, Isabella Buber-Ennser, Bernhard Rengs, Sebastian Leitner, and Michael Landesmann. (2019). Barriers to health care access and service utilization of refugees in Austria: Evidence from a cross-sectional survey. Health Policy, 123(2019):833-839. Jules Morgan. (2016). Frontline: Providing health care in Greeceâ&#x20AC;&#x2122;s refugee camps. The Lancet, 388:748. Leigh Daynes. (2016). The health impacts of the refugee crisis: a medical charity perspective. Clinical Medicine, 16(5):437-440. M. Catchpole and D. Coulombier. (2015). Refugee crisis demands European Union-wide surveillance!. European Surveillance, 20(45):1-2. Merve Ay, Pedro A. Gonzalez, and Rafael C. Delgado. (2016). The Perceived Barriers of Access to Health Care Among a Group of Non-camp Syrian Refugees in Jordan. International Journal of Health Service, 0(0):1-14. Ministry of Health Indoneisa. (2018). Peraturan Menteri Kesehatan Republik Indonesia Nomor 47 Tahun 2018 Tentang Pelayanan Kegawatdaruratan. Berita Negara Republik Indonesia Tahun 2018 Nomor 1799. Jakarta. Nefti-Eboni Bempong, Danny Sheath, Joachim Seybold, Antoine Flahault, Anneliese Depoux, and Luciano Saso. (2019). Critical reflection, challenges and solution for migrant and refugee health: 2nd M8 Alliance Expert Meeting. Public Health Reviews, 40(3):1-12.

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Peta J. Masters, Penelope J. Lanfranco, Emmy Sneath, Amanda J. Wade, Sarah Huffam, James Pollard, James Standish, Kate McCloskey, Eugene Athan, Daniel P. O’Brien, and N. Deborah Friedman. (2018). Health issues of refugees attending an infectious disease refugee health clinic in a regional Australian Hospital. Australian Journal of General Practice, 47(5):305-310. Ranit Mishori, Shoshana Aleinikoff, and Dawn Davis. (2017). Primary Care for Refugees: Challenges and Opportunities. American Family Physician, 96(2):112-122. Sally Cutler. (2015). Refugee crisis and re-emergence of forgotten infection in Europe. Clinical Microbiology and Infection, 22(1):8-9. Shanon Doocy, Emily Lyles, Laula Akhu-Zaheya, Ann Burton, and Gilbert Burnham. (2016). Health service access and utilization among Syrian refugee in Jordan. International Journal for Equity in Health, 15(108):1-15. Syed S. Mahmood, Emily Wroe, Arlan Fuller, and Jennifer Leaning. (2017). The Rohingya people of Myanmar: health, human rights, and identity.

The Lancet,

389(10081):1841-1850. Theresa Alfaro-Velcamp. (2016). “Don’t send your sick here to be treated our own people need it more”: immigrants’ access to healthcare in South Africa. International Journal of Migration, Health and Social Care, 13(1):53-68. United Nations. (2017). Population Facts. World Health Organization: United Nations Department of Economic and Social Affairs Population Division. Retrieved from United

Nations:

https://www.un.org/en/developdeve/desa/population/publicatipub/pdf/popfacts/Pop Facts_2012-5.pdf, access on September 2019. United Nation of High Commissioner for Refugees (UNHCR). (2019). Figures at a glance: Statistical Yearbooks. Retrieved from UNHCR: https://www.unhcr.org/figures-at-aglance.html, access on September 2019. Vanessa Johnston, Le Smith, and Heather Roydhouse. (2012). The health of newly arrived refugees to the Top End of Australia: results of a clinical audit at the Darwin Refugee Health Service. Australian Journal of Primary Health, 18:242-247. World Health Organization. (2019). 10 things to know about the health of refugees and migrants. Retrieved from World Health Organization: https://www.who.int/news-

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room/feature-stories/detail/10-things-to-know-about-the-health-of-refugees-andmigrants, access on September 2019.

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Rescue Breathing in Cardiopulmonary Resuscitation: Does It Really Matter? An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trial with Trial Sequence Analysis and Future Insight Ignatius Ivan*, Fanny Budiman*, Rivaldi Ruby** * Fourth Year Medical Student, Atma Jaya Catholic University of Indonesia ** Second Year Medical Student, Atma Jaya Catholic University of Indonesia Abstract Aim: This updated systematic review and meta-analysis with Trial Sequence Analysis (TSA) aims to provide the evidence of conclusive effect for survival benefit between continuous-chest compression (CCC) versus standard (STD) cardiopulmonary resuscitation (CPR) while reassess the quality of evidence and suggest the necessity for future research. Background: Debate between CCC-CPR and STD-CPR with interrupted rescue breathing remains controversial. Although previous meta-analyses appeared to be favoring CCC-CPR, it is estimated that many meta-analyses on intervention in critical care which are believed to be conclusive apparently may be inconclusive. Methodology: Our systematic review followed the PRISMA guidelines. We searched PubMed, ScienceDirect, EBSCOhost, and ProQuest database from 1985 to 26 September 2019 restricted to randomized controlled trial (RCT), human study, and english article. We performed quality assessment of each included study and data analyses, between-study heterogeneity evaluation and a TSA. Indicating statistical significance, we used two-sided 95% confidence interval (CI). We estimated the overall significance for the analyses with 80% power and adjusted the thresholds for Z values using O’Brien–Fleming α-spending function to allow the type-1 error risk to be restored to the desired maximum risk. The risk of a type-2 error was controlled using β-spending function and futility boundaries. Heterogeneity correction was performed based on model variance. We determined the required meta-analysis information size with 21% relative risk using the estimation between group incidences provided from the median rate across trials. When TSA revealed inconclusive result, we estimated the size of future RCT to conclude the result. The quality of evidence was analyzed using GRADE Handbook assisted with TSA. Key Findings: Our pooled results from meta-analyses is similar with previous findings. However, we found that three studies evaluated from current and previous meta-analyses appeared to be inconclusive and thus need further trials. There is a significant risk of type-1

131

error and therefore, results are potentially false positive. Quality of evidence is downgraded to moderate in this study due to serious imprecision based on findings from TSA. Our position regarding this issue is that we donâ&#x20AC;&#x2122;t have enough evidence to conclude which method of CPR is superior towards each other.

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Rescue Breathing in Cardiopulmonary Resuscitation: Does It Really Matter? An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trial with Trial Sequence Analysis and Future Insight Ignatius Ivan*, Fanny Budiman*, Rivaldi Ruby** * Fourth Year Medical Student, Atma Jaya Catholic University of Indonesia ** Second Year Medical Student, Atma Jaya Catholic University of Indonesia Introduction Cardiac arrest is the third leading cause of death worldwide (Gu & Li, 2017). Despite the advancement of technology nowadays, especially in handling cardiovascular disease, in hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) remains the leading cause of mortality and morbidity globally. In the developing countries, OHCA contributes around 10% of the total mortality of developing countries (Mawani et al., 2016). The key predictors of survival in OHCA patients are determined by immediate bystander cardiopulmonary resuscitation (CPR), early defibrillation, early emergency medical services (EMS) response, and post resuscitation care (Mawani et al., 2016). These steps are commonly known as the “chain of survival”. As part of the “chain of survival”, CPR holds a major part in increasing chances of living in OHCA patients. The goal of CPR is to maintain oxygenation until spontaneous circulation is restored (Nichol et al., 2015). Current CPR includes chest compressions and rescue breathing, either with mouth-to-mouth ventilation or artificial device. While standard chest compression (STD) include chest compressions and rescue breathing at a fixed ratio either 15:2 or 30:2, continuous chest compressions (CCC) requires no rescue breathing and thus increasing the rate of chest compressions per minute. The debate between CCC-CPR and STD-CPR with interrupted rescue breathing remains controversial, as one side offers the advantage of allowing the circulation to keep ongoing, while the STD-CPR helps with ventilation problems. The 2015 International Consensus on CPR and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) recommends continuous chest compression CPR for adults with suspected OHCA. CCC-CPR is simpler, easier to learn, and perform. AHA also stated that CCC-CPR is as effective as STDCPR for cardiac arrest at home, at work or in public (Garg et al., 2017). So, it is expected to increase the rate of OHCA patients receiving bystander CPR.

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The increasing rate of patients receiving bystander CPR is major in strengthening the overall “chain of survival”. The willingness to perform CPR is associated with fear of acquiring infectious diseases from performing mouth-to-mouth ventilation (Zhan, Yang, Huang, He & Liu, 2017). Sense of panic and cultural beliefs also prevented many bystanders to perform CPR (Garg et al., 2017; Nofzinger et al., 2019). It is interesting to note that women with OHCA are less often receiving bystander CPR than man (Perman et al., 2019). The reasons behind this fact are fear of being accused of inappropriate touch or doing sexual assault. CCC-CPR offers higher number of chest compressions due to uninterrupted chest compressions (Gianotto-Oliveira et al., 2015). Previous studies stated that higher chest compression rates were significantly correlated with return of spontaneous circulation and better neurologic function (Lee, Hong & Oh, 2018; Nichol et al., 2015). However, the major concern of CCCCPR is rescuer’s fatigue that may impact the quality of chest compressions (Gianotto-Oliveira et al., 2015). Meanwhile, some studies (Gianotto-Oliveira et al., 2015; Shin et al., 2014) stated better overall quality of chest compression with STD-CPR. High quality chest compressions are determined by chest compression depth and associated with better patient outcomes. Chest compression depth decreases more slowly with STD-CPR method with ratio 30:2 (Lee, Hong & Oh, 2018). Although there are lots of studies stating STD-CPR as better options, the previous metaanalyses (Zhan, Yang, Huang, He & Liu, 2017; Yang, Wen, Li & Shi, 2012; Cabrini et al., 2010; Hüpfl, Selig & Nagele, 2010) appeared to be favoring CCC-CPR. Using Trial Sequence Analysis (TSA), it is revealed that many meta-analyses regarding intervention in critical care that are believed to be conclusive apparently are inconclusive (Koster et al., 2019). This might be due to lack of evaluation on risk of type-1 or type-2 errors. TSA can also quantitatively evaluate imprecision for grading of the confidence in the estimate. Many authors of meta-analysis have various methods in assessing imprecision but TSA is more reliable to evaluate imprecision (Castellini, Bruschettini, Gianola, Gluud & Moja, 2018). Previous meta-epidemiological study assessing studies from Cochrane systematic reviews showed that many studies rarely report their methods for assessing imprecision. It is estimated that review authors downgraded 48% of key outcome due to imprecision, and when re-analyzed following Grading of Recommendations Assessment, Development and Evaluation (GRADE) Handbook, 64% of outcomes were downgraded. Meanwhile, when reanalyzed with TSA in addition with GRADE, reviews are downgraded up to 69%. This shows that TSA may assist the development of better evaluation.

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This updated systematic review and meta-analysis aims to elucidate the current evidence of survival benefit of CCC-CPR versus STD-CPR method by using TSA in the setting of nonasphyxial OHCA while reassess the quality of evidence and suggest the necessity for future research. Methodology A structured search of the literature was conducted to identify research on the effect of CCC versus STD method in CPR of non-asphyxial OHCA to analyse survival to hospital discharge, using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement guideline, with a pre-determined search strategy (Appendix 1) (Moher et al., 2015). The search was conducted in PubMed, ScienceDirect, EBSCOhost, and ProQuest while restricted to randomized controlled trials, human studies, published in English, between 1985 and 26 September 2019. We complemented the search strategy using the [All Field], to include terms not found using MeSH term (Appendix 2). The search strategy identified 1486 studies. Results were imported into Endnote X9, duplicates are removed, and leaving 866 articles to review. The abstracts of these 866 articles were reviewed for relevance by two authors (II and FB), based on the following criteria: sample size justification, relevant outcome, study design, and results. After screening, 17 studies were retained for full review. Out of 17 studies, 3 studies were ultimately retained for analysis, based on following criteria: sufficient statistical power; population characteristics defined; inclusion of participant characteristic which are adult (>19 years old), non-asphyxial, OHCA patients; and results can be measured quantitatively. The other 14 studies were excluded for the following reasons: one study is an editorial letter (Gold et al., 2008), one study is a commentary (Hui et al., 2010), four studies are observational studies (Dumas et al., 2013; Kitamura et al., 2010; Panchal et al., 2013; Japanese Circulation Society Resuscitation Science Study Group, 2013), one study is an ongoing clinical trial (Brown et al., 2015), six studies are reviews (Cunningham et al., 2012; Drager et al., 2012; Meier et al., 2010; Yang et al., 2012; Yao et al., 2014; Zhan et al., 2017), and one study is in the settings of in hospital care (Nichol et al., 2015). Any disagreement will be resolved through discussion with the third author (RR). To assess the bias, we (II and FB) used the Cochrane Risk of Bias Tool 2.0 (Higgins et al., 2016) (Fig. 1), which covers the following 6 domains of risk: random sequence generation (bias arising from the randomization process); allocation concealment (bias arising from the randomization process); blinding of participants and personnel (bias due to deviations from intended interventions); blinding of outcome assessment (bias in measurement of the outcome); incomplete outcome data (bias due to missing outcome data); and selective reporting (bias in

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selection of the reported result). A third review author (RR) helped to resolve any disagreements through discussion. The risk of bias in each of these domains is scored as “low,” “high,” or “unclear.” Data analyses were performed by two authors (II and FB) using Review Manager 5.3 software (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration). We applied fixedeffect and random-effects models to evaluate outcomes of studies in accordance with low and considerable between-study heterogeneity, respectively (Higgins et al., 2008). Between-study heterogeneity was evaluated using the Cochran Q test (v2). We quantified inconsistency in heterogeneity by calculating the I2-value, interpreted as follows: 0–25% heterogeneity might not be important; 25–75% may represent moderate heterogeneity; and 75– 100% may represent considerable heterogeneity (Higgins et al., 2008). When more than 10 studies were available, we constructed funnel plots and evaluated their symmetry visually for publication bias. We reported the results of our analysis as a forest plot with 95% CIs. We performed a TSA, using the Trial Sequential Analysis Software (version 0.9.5.5 Beta; Copenhagen Trial Unit, Copenhagen, Denmark), as shown in Fig. 3 (Thorlund et al., 2017). In order to control the risk of a type-1 error, we adjusted the thresholds for the Z values using the O’Brien–Fleming α-spending function, allowing the type-1 error risk to be restored to the desired maximum risk. Crossing the O’Brien–Fleming α-spending boundaries with the Z-curve was used to identify statistical significance (Thorlund et al., 2017). The risk of a type-2 error was controlled using the β-spending function and futility boundaries. Crossing the futility boundaries with the Z-curve was used to determine if two interventions do not differ more than the anticipated intervention effect (Thorlund et al., 2017). A two-sided 95% CI was used to indicate statistical significance in all analyses. We determined the required meta-analysis information size with 21% relative risk, assuming STD-CPR group incidence rate of 11,6% and CCC-CPR group incidence rate of 14,04% (approximately the median rate across trials). We calculated the information size required to yield “moderate” meta-analytic evidence based on an α = 5% significance level, and β = 20% (80% power). Heterogeneity correction was based on model variance. When TSA revealed inconclusive result, we estimated the size of future RCT in order to conclude the result. Required sample size was estimated for a future RCT to achieve moderate evidence (α= 5% and β= 20%) of detecting 21% relative risk for survival to hospital discharge

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with STD-CPR group incidence rate of 11,6% and CCC-CPR group incidence rate of 14,04%, thus enabling cumulative-Z-statistic crossed the trial sequential monitoring boundaries. Finally, the quality of evidence was evaluated according to the GRADE Handbook (Zhang et al., 2019; Zhang & Alonso-Coello et al., 2019) for risk-of-bias, inconsistency, indirectness, imprecision, and publication bias, with the level of quality classified as “high,” “moderate,” “low,” or “very low” (Zhang & Alonso-Coello et al., 2019; Balshem et al., 2011). We used GRADEpro software in presenting the quality of evidence (GRADEpro GDT, 2015). Result Study Selection The electronic search from multiple database identified a total of 1486 studies, of which 17 were eligible based on the title and abstract. By applying our inclusion and exclusion criteria, we finally included 3 RCTs in our final analysis. Study Characteristics Characteristics of the included studies are summarized in Table 1. The studies included 3031 patients (1500 on CCC-CPR group and 1531 on STD-CPR. All studies were performed in OHCA patients and stated that the updated international basic life support and advanced life support guidelines were followed strictly. Table 1. Characteristics of the included studies Author

Study Design

Age

(Year)

CCC-

STD-

Witnessed

Call to

CPR

arrest (%)

ALS arrival (minutes)

Hallstrom

518

(2000) Rea (2010)

Randomized

68.2

240

278

63.7

978

956

6,5

67.5

620

656

100

Controlled Trial 1934

Randomized Controlled Trial

Svensson (2010)

579

Randomized Controlled Trial

CCC-CPR: Continuous Chest Compressions, STD-CPR: Standard CPR, ALS: Advanced Life Support

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Risk of Bias Figure 1 summarized the risk of bias based on authors judgments. Regarding random sequence generation, there was unclear risk in the study by Rea et al. (2010). Of note there was also unclear risk regarding allocation concealment by Hallstrom et al. (2000). Also, there were high risks of performance bias in the study of Rea et al. (2010) and Svensson et al. (2010).

Figure 1. Risk of bias summary: review authors’ judgements about each risk of bias item for each included study. Allocation. Randomization in study by Rea et al. (2010) was not described. The other two studies used computer to randomize the number sequence. We considered that studies belong to Rea et al., (2010) and Svensson et al. (2010) had adequate allocation concealment. In study belongs to Hallstrom et al. (2000), we considered there was an unclear risk of selection bias because the allocation was determined by a microcomputer at the dispatcher’s console and thus no further information was stated. Blinding. In study by Hallstrom et al. (2000), the EMS personnel and the emergency physicians were blinded. In the other two studies, the EMS personnel and the physicians were not blinded. The bystanders were not blinded in all studies, but they didn’t know that they were participating in the trial, so we considered this to have no effect on the studies. The fact that the participants were unconscious and not breathing normally supported the idea that the blinding of the bystanders doesn’t affect the outcome of the studies. Therefore, the risk of performance bias appears to be low on study by Hallstrom et al. (2000) and high in the other two studies (Rea et al., 2010; Svensson et al., 2010). All studies had low risks of detection bias. Two studies reported blinded outcome assessment (Hallstrom et al., 2000; Rea et al., 2010). In study by Svensson et al. (2010), data were collected

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from EMS records and information about survival statues were collected from national registers. The data collection forms were double-checked and there are no relevant deviations were observed. The researchers also evaluated recorded calls and reviewed the data forms. There was no deviation of the information. Incomplete outcome data. The risk of attrition bias was found to be low due to low percentage of missing data in all studies. Study by Hallstrom et al., (2000) reported two participants’ data were missing. Study by Rea et al., (2010) reported the percentage of missing data was 1.7% in both groups. Study by Svensson et al., (2010) reported the percentage of missing data was 6.8%, but to compensate, the authors made a subgroup analysis excluding the districts with more than 18% participants that were lost to follow up. No difference with the main results was found. Selective reporting. The outcomes of OHCA patients have been reported as recommended by the Utstein Style in all studies. So, we considered all studies to be at low risk of reporting bias. Survival to Hospital Discharge Survival to hospital discharge was defined as the patient leaving the hospital alive post cardiac arrest event. Meta-analyses of 3 RCTs (n = 3031) showed better outcome in the CCC-CPR group. Results of the studies are summarized in Fig. 2. These studies include survival to hospital discharge as their outcome measure to evaluate the effectiveness of CCC-CPR compared to STD-CPR. The pooled results from meta-analysis showed a significance for CCC-CPR affecting survival to hospital discharge, compared to STD-CPR (211/1500 [14.1%] vs 178/1531 [11.6%], RR= 1.21[1.01-1.46], 95% CI, p=0.04). The between-study heterogeneity was not significant (I2 0%, p=0.68; Fig. 2). The likelihood of publication bias was not assessed because there were less than ten studies involved in the analysis.

Figure 2. Forest plot of comparison between CCC-CPR versus STD-CPR provided from bystanders with outcome of survival to hospital discharge. The solid squares denote the risk ratio, with the horizontal lines indicating the 95% confidence intervals and the diamond denotes the pooled effect size. CCC-CPR, continuous chest compression-cardiopulmonary resuscitation; CI, confidence interval; Chi2 , chi-squared statistic; df , degrees of freedom; I2 , I-squared heterogeneity statistic; p , p value; SD , standard deviation; STD-CPR, standard cardiopulmonary resuscitation; Z, Z statistic;

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Quality of Evidence The quality of evidence, evaluated as per the GRADE Handbook (Table 2), was classified as being “moderate certainty” and thus, there is a possibility that the true effect is substantially different from the estimated effect. This limitation results from serious imprecision due to results from TSA revealed that the cumulative Z curve doesn’t cross trial sequential monitoring boundary and fail to meet required size. Other certainty assessment appeared to be not serious. For risk of bias, the study has low risk of bias and across subdomains (selection of participants into the study, completeness of data, measurement of instrument, data analysis). There is low inconsistency as shown by the pooled results from meta-analysis (I2 = 0, p = 0,68). Points estimated are similar and confidence interval are overlap. No serious indirectness due to PICO and methodological elements. Based on absolute effect auto calculation from GradePRO, the difference in survival to hospital discharge is about 24 more people per 1000 following bystander administered continuous chest compression (GRADEpro GDT, 2015). Table 2. Evaluation of the Quality of the Evidence Based on the GRADE Handbook

Trial Sequence Analysis

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Figure 3. Results of the trial sequential analysis (TSA), measuring the risk ratio between CCC versus STD CPR for survival to hospital discharge.The cumulative Z curve didn’t cross the trial monitoring boundary for CCC-CPR before required information size was reached,confirming that the measured outcomes are inconclusive, thus further trials are required. Brown line, Conventional Test Boundary; Blue line, Two-Sided Cumulative ZCurve; Red Line: Trial Sequential Monitoring Boundary(O’Brien-Fleming’s Boundary).CCCCPR, continuous chest compression-cardiopulmonary resuscitation; STD-CPR, standard cardiopulmonary resuscitation Figure 3 shows the result of TSA of meta-analyses of three trials measuring the risk ratio between CCC-CPR versus STD CPR for survival to hospital discharge. The TSA shows that the three trials failed to cross trial monitoring boundaries (red line curves above and below the traditional horizontal lines for statistical significance) to confirm or reject a better survival toward CCC-CPR group. Thus, this results is inconclusive when adjusted for sequential testing on an accumulating number of participants and furhter trials are required.

Figure 4. Results of the trial sequential analysis (TSA) after added with hypothetical study, measuring the risk ratio between CCC versus STD CPR for survival to hospital discharge. After adding 1300 more patients enrolled in RCT with the assumption of STD group incidence rate of 11,6% while a CCC group incidence rate of 14,04%. The cumulative Z curve eventually cross the trial monitoring boundary for CCC-CPR before required information size was reached, confirming that the measured outcomes are conclusive and, thus, further trials are not required. Brown line, Conventional Test Boundary; Blue line, TwoSided Cumulative Z-Curve; Red Line: Trial Monitoring Boundary (O’Brien-Fleming’s Boundary). CCC-CPR, continuous chest compression-cardiopulmonary resuscitation; STDCPR, standard cardiopulmonary resuscitation

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In Figure. 4, after adding 1300 additional patients for RCT from hypothetical study with assumption of STD-CPR group incidence rate of 11,6% while a CCC group incidence rate of 14,04%, TSA revealed a conclusive meta-analysis as cumulative Z curve cross the trial monitoring boundary in favor of CCC-CPR. This is necessary to eventually stop to create new trial as the result has been revealed to be conclusive with moderate evidence. Discussion

Our systematic review regarding the measurement of CCC versus STD CPR survival to hospital discharge was based on three trials of bystander-initiated CPR done in randomized controlled trial, reporting for 3031 patients. The use of CCC-CPR method produce a better survival (RR: 1.21, 95% CI: 1.01 to 1.46). It is estimated that when CCC-CPR method is applied there will be about 24 more people per 1000 to be survive to hospital discharge. Based on the survival benefit from this meta-analyses, International Liaison Committee on Resuscitation (ILCOR) has released a consensus statement in which suggesting CCC-CPR method during CPR for OHCA. Although many meta-analyses had been done since 2010 (Zhan, Yang, Huang, He & Liu, 2017; Yang, Wen, Li & Shi, 2012; Cabrini et al., 2010; HĂźpfl, Selig & Nagele, 2010) revealed the same outcome in which favoring CCC-CPR method, our findings from database searching revealed that there are no additional studies we can include by the end of our searching. We recognized that all previous meta-analyses of randomized controlled trial has been using the same three studies while there has been no study that can conclusively elucidate the survival benefit from using CCC-CPR methods. As only three studies were available for inclusion in our analysis, we used TSA to provide more conservative estimate of the noted effect of CCCCPR method. TSA results indicated that estimated survival benefit of CCC-CPR method are inconclusive and thus, can not be accepted with the need for further trials required. Having only surpassed the conventional boundaries but not the trial monitoring boundaries, can increase the risk of type-1 error as conventional significance testing in meta-analysis fails to relate observed test statistics and p-values to the strength of the available evidence and to the number of repeated significance tests. The risk of type 1 error is 10% to 30% as repeated significance testing result updated from new study with conventional Îą=5% threshold, 1.96 (Thorlund et al., 2017). Other findings from three trials are unable to be quantitatively analyzed using pooled metaanalyses due to limited study available. One trial measure the outcome of survival to hospital admission (Hallstrom et al., 2000) and one trial analyzed the neurological outcome at hospital discharge (Rea et al., 2010). Both findings revealed no significant difference between the group.

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All three trials included OHCA and excluded asphyxial arrests. Common cause of cardiac arrest was similar accross studies which are ventricular fibrillation, asystole, pulseless electrical activity and ventricular tachycardia. Currently there has been no study assessing the effect of different guidelines on the clinical therapy, thus the clinical heterogeneity produced due to advanced life support methods followed from different guidelines can be considered negligible. Our estimation revealed an inference on the number of new patients need to be enrolled in RCT in order to provide conclusive and moderate evidence of meta-analyses. Using ‘topping up’ a sample size method to approximate new number of patient required, we use similar risk profile and revealed a requirement of 1300 more patients needed to be randomized in future trial. We decided to downgrade one level of evidence for imprecision assessment due to failure of reaching required information size. This hasn’t been done before in previous meta-analyses as the level of evidence remain high. The quality of evidence which helps physician to make reliable clinical decisions, was deemed to be moderate, based on GRADE Handbook and thus the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Conclusion Our pooled results from meta-analysis is similar with previous findings. However, we found that three studies evaluated from current and previous meta-analyses appeared to be inconclusive and thus need further trials. There is a significant risk of type 1 error and therefore, results are potentially false positive. Quality of evidence is downgraded to moderate in this study due to serious imprecision based on findings from TSA. Our position regarding this issue is that we don’t have enough evidence to conclude which method of CPR is superior towards each other. Recommendations For future researches, study with larger population (1300 patients with the assumption of having similar risk profile) enrolled in RCT, needs to be conducted in order to reach conclusive metaanalysis with insignificant risk of type 1 error.

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References Balshem, H et al. (2011). GRADE guidelines: 3. Rating the quality of evidence. Journal of Clinical Epidemiology, 64(4), 401â&#x20AC;&#x201C;406. doi: 10.1016/j.jclinepi.2010.07.015 Brown, S., Wang, H., Aufderheide, T., Vaillancourt, C., Schmicker, R., & Cheskes, S. et al. (2015). A randomized trial of continuous versus interrupted chest compressions in out-of-hospital cardiac arrest: Rationale for and design of the Resuscitation Outcomes Consortium Continuous Chest Compressions Trial. American Heart Journal, 169(3), 334-341.e5. doi: 10.1016/j.ahj.2014.11.011 Cabrini, L., Biondi-Zoccai, G., Landoni, G., Greco, M., Vinciguerra, F., & Greco, T. et al. (2010). Bystander-initiated chest compressiononly CPR is better than standard CPR in out-of-hospital cardiac arrest. HSR Proceedings in Intensive Care and Cardiovascular Anesthesia, 2(4), 279-285. Castellini, G., Bruschettini, M., Gianola, S., Gluud, C., & Moja, L. (2018). Assessing imprecision in Cochrane systematic reviews: a comparison of GRADE and Trial Sequential Analysis. Systematic Reviews, 7(1). doi: 10.1186/s13643-018-0770-1 Cunningham, L., Mattu, A., O'Connor, R. and Brady, W. (2012). Cardiopulmonary resuscitation for cardiac arrest: the importance of uninterrupted chest compressions in cardiac arrest resuscitation. The American Journal of Emergency Medicine, 30(8), pp.1630-1638. doi: 10.1016/j.ajem.2012.02.015 Dumas, F., Rea, T., Fahrenbruch, C., Rosenqvist, M., FaxĂŠn, J., & Svensson, L. et al. (2013). Chest Compression Alone Cardiopulmonary Resuscitation Is Associated with Better Long-Term Survival Compared with Standard Cardiopulmonary Resuscitation. Circulation, 127(4), 435-441. doi: 10.1161/circulationaha.112.124115 Drager, K. (2012). Improving Patient Outcomes with Compression-Only CPR: Will Bystander CPR Rates Improve?. Journal of Emergency Nursing, 38(3), pp.234-238. doi: 10.1016/j.jen.2011.02.008 GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. (2015). McMaster University. Retrieved September 27, 2019, from https://gradepro.org/ Garg, R., Ahmed, S., Divatia, J., Rao, S., Mishra, B., & Kalandoor, M. et al. (2017). Compression-only life support (COLS) for cardiopulmonary resuscitation by layperson outside the hospital. Indian Journal of Anaesthesia, 61(11), 867. doi: 10.4103/ija.ija_636_17 Gianotto-Oliveira, R., Gianotto-Oliveira, G., Gonzalez, M., Quilici, A., Andrade, F., Vianna, C., & Timerman, S. (2015). Quality of continuous chest compressions performed for one or two minutes. Clinics, 70(3), 190-195. doi: 10.6061/clinics/2015(03)07 Gold, L. and Eisenberg, M. (2008). Chest-Compression-Only vs. Standard Cardiopulmonary Resuscitation: Shouldn't We Wait for More Evidence?. Prehospital Emergency Care, 12(3), pp.406-409. doi: 10.1080/10903120802096696. Gu, W., & Li, C. (2017). Ventilation strategies during out-of-hospital cardiac arrest: a problem that should not be neglected. Journal of Emergency and Critical Care Medicine, 1(9), 23-23. doi: 10.21037/jeccm.2017.08.08 Hallstrom, A., Cobb, L., Johnson, E., & Copass, M. (2000). Cardiopulmonary Resuscitation by Chest Compression Alone or with Mouth-to-Mouth Ventilation. New England Journal of Medicine, 342(21), 1546-1553. doi: 10.1056/nejm200005253422101 Higgins, J. PT et al. (2016). A revised tool for assessing risk of bias in randomized trials. Cochrane Database of Systematic Reviews, 10(Suppl 1), 29-31.

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Higgins, JP., Green, S. (2008). Cochrane Handbook for Systematic Reviews of Interventions. Chichester, UK: John Wiley & Sons, Ltd. Hui, C. and Brindley, P. (2010). Continuous chest compression cardiopulmonary resuscitation following out-of-hospital cardiac arrest. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 58(3), pp.330-333 doi: 10.1007/s12630-010-9426-x. Hüpfl, M., Selig, H., & Nagele, P. (2010). Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. The Lancet, 376(9752), 1552-1557. doi: 10.1016/s01406736(10)61454-7 Japanese Circulation Society Resuscitation Science Study Group. Chest-Compression-Only Bystander Cardiopulmonary Resuscitation in the 30:2 Compression-to-Ventilation Ratio Era. (2013). Circulation Journal, 77(11), 2742-2750. doi: 10.1253/circj.cj-13-0457 Kitamura, T., Iwami, T., Kawamura, T., Nagao, K., Tanaka, H., Nadkarni, V., Berg, R. and Hiraide, A. (2010). Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study. The Lancet, 375(9723), pp.1347-1354. doi: 10.1016/S0140-6736(10)60064-5 Kleinman, M., Perkins, G., Bhanji, F., Billi, J., Bray, J., & Callaway, C. et al. (2018). ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement. Circulation, 137(22). doi: 10.1161/cir.0000000000000561 Koster, T., Wetterslev, J., Gluud, C., Jakobsen, J., Kaufmann, T., & Eck, R. et al. (2019). Apparently conclusive meta-analysis on interventions in critical care may be inconclusive—a metaepidemiological study. Journal of Clinical Epidemiology, 114, 1-10. doi: 10.1016/j.jclinepi.2019.05.011 Lee, S., Hong, J., & Oh, J. (2018). Why should we switch chest compression providers every 2 minutes during cardiopulmonary resuscitation?. Signa Vitae - A Journal in Intensive Care and Emergency Medicine, 14(2). doi: 10.22514/sv142.102018.4 Mawani, M., Kadir, M., Azam, I., Mehmood, A., McNally, B., & Stevens, K. et al. (2016). Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study. BMC Emergency Medicine, 16(1). doi: 10.1186/s12873-016-0093-2 Meier, P., Baker, P., Jost, D., Jacobs, I., Henzi, B., Knapp, G. and Sasson, C. (2010). Chest compressions before defibrillation for out-of-hospital cardiac arrest: A meta-analysis of randomized controlled clinical trials. BMC Medicine, 8(1). doi: 10.1186/1741-7015-8-52 Moher, D et al. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1). doi: 10.1186/2046-4053-4-1 Nichol, G., Leroux, B., Wang, H., Callaway, C., Sopko, G., & Weisfeldt, M. et al. (2015). Trial of Continuous or Interrupted Chest Compressions during CPR. New England Journal of Medicine, 373(23), 2203-2214. doi: 10.1056/nejmoa1509139 Nofzinger, J., Kakish, E., Bahhur, N., Ryno, J., Pillai, M., DeBelly, J., & Jones, C. (2019). Effectiveness of Hands-Only Cardiopulmonary Resuscitation Teaching on Lay Bystander Attitudes Toward Future Resuscitation. Spartan Medical Research Journal, 4(1), 1-6. Retrieved from https://smrj.scholasticahq.com/article/8749-effectiveness-of-hands-only-cardiopulmonaryresuscitation-teaching-on-lay-bystander-attitudes-toward-future-resuscitation Panchal, A., Bobrow, B., Spaite, D., Berg, R., Stolz, U., Vadeboncoeur, T., Sanders, A., Kern, K. and Ewy, G. (2013). Chest compression-only cardiopulmonary resuscitation performed by lay rescuers for adult out-of-hospital cardiac arrest due to non-cardiac aetiologies. Resuscitation, 84(4), pp.435439. doi: 10.1016/j.resuscitation.2012.07.038

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Perman, S., Shelton, S., Knoepke, C., Rappaport, K., Matlock, D., & Adelgais, K. et al. (2019). Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation Than Men in Out-of-Hospital Cardiac Arrest. Circulation, 139(8), 1060-1068. doi: 10.1161/circulationaha.118.037692 Rea, T., Fahrenbruch, C., Culley, L., Donohoe, R., Hambly, C., & Innes, J. et al. (2010). CPR with Chest Compression Alone or with Rescue Breathing. New England Journal of Medicine, 363(5), 423-433. doi: 10.1056/nejmoa0908993 Shin, J., Hwang, S., Lee, H., Park, C., Kim, Y., & Son, Y. et al. (2014). Comparison of CPR quality and rescuer fatigue between standard 30:2 CPR and chest compression-only CPR: a randomized crossover manikin trial. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22(1). doi: 10.1186/s13049-014-0059-x Svensson, L., Bohm, K., Castrèn, M., Pettersson, H., Engerström, L., Herlitz, J., & Rosenqvist, M. (2010). Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest. New England Journal of Medicine, 363(5), 434-442. doi: 10.1056/nejmoa0908991 Thorlund, K., Engstrøm, J., Wettersley, J., Brok, J., Imberger, G., Gluud, C. (2017). User Manual for Trial sequential analysis (TSA). Denmark: Copenhagen Trial Unit, Chapter. 2. Yang, C., Wen, J., Li, Y., & Shi, Y. (2012). Cardiocerebral resuscitation vs cardiopulmonary resuscitation for cardiac arrest: a systematic review. The American Journal Of Emergency Medicine, 30(5), 784-793. doi: 10.1016/j.ajem.2011.02.035 Yao, L., Wang, P., Zhou, L., Chen, M., Liu, Y., Wei, X. and Huang, Z. (2014). Compression-only cardiopulmonary resuscitation vs standard cardiopulmonary resuscitation: an updated meta-analysis of observational studies. The American Journal of Emergency Medicine, 32(6), pp.517-523. doi: 10.1016/j.ajem.2014.01.055. Zhan, L., Yang, LJ., Huang, Y., He, Q., Liu, GJ. (2017). Continuous chest compression versus interrupted chest compression for cardiopulmonary resuscitation of non-asphyxial out-of-hospital cardiac arrest. Cochrane Database of Systematic Reviews, (3), 1-46. doi: 10.1002/14651858.CD010134.pub2 Zhang, Y., Alonso-Coello, P et al. (2019). GRADE Guidelines: 19. Assessing the certainty of evidence in the importance of outcomes or values and preferences—Risk of bias and indirectness. Journal of Clinical Epidemiology, 111, 94–104. doi: 10.1016/j.jclinepi.2018.01.013 Zhang, Y et al. (2019). GRADE guidelines: 20. Assessing the certainty of evidence in the importance of outcomes or values and preferences—inconsistency, imprecision, and other domains. Journal of Clinical Epidemiology, 111, 83–93. doi: 10.1016/j.jclinepi.2018.05.011

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Appendix Appendix 1: Flow diagram of the identification and selection of studies included in the analysis.

147

Appendix 2: Terms used in literature search

148

Disaster Medicine : An Urgent Needs for Doctor in Indonesia A Systematic Review

Michelle Gracella, Lestari Eka Putri, Al – As’ari, Fani Nadila Faculty of Medicine and Health Science, University of Jambi – Jambi, Indonesia Aim : to present references for medical school in Indonesia can use to arrange Disaster Medicine subject for their students Background : Indonesia is a “supermarket disaster”. Indonesia is one of the five country that hit the most by natural disaster. In fact, disaster medicine is rarely implemented in medicine education in Indonesia. It is ashame, because the pysicians were frequently commanded to take a lead on facing disaster event. A practical disaster regulation in Indonesia was only reaction on field without any scientific based. Therefore disaster medicine is needed in Indonesia. Hopefully, disaster medicine can be implemented and will show better outcome in disaster preparedness in Indonesia. Method : This study using journals that earnt scientific sources : pubMed, cambridge core journal, and goggle scholar. The search using certain criteria to ensure the eligibilty and reliable on tis study. After several assesment, we got 26 journals (n=26) as material of this study. We also gathered view grey literature from GO and NGO to provide all data that is needed for butter understanding on the study. Result : From 26 journals, after the thematic analysis, we received many teaching methods that used in disaster medicine all over the world. From lectures, skill station, case study simulation, and other motivative way such as using video games or game based learning (GBL) alsro we retrieved competences that tought on distaser medicine. The compatences are include soft skill, emergency skill, and disaster preparedness regulation. Conclusion : Disaster medicine are surely needed in Indonesia as a most hitted by natural disaster. Many ways can be implement in disaster medicine. And those competences in disaster medicine can be really helpful for the physicians to act on disaster event. So, we strongly suggest to implement disaster medicine in Indonesia’s medical curriculum. Keywords : Disaster medicine, teaching, curriculum.

149

Disaster Medicine: An Urgent Needs for Doctor in Indonesia A Systematic Review

Author : Michelle Gracella Lestari Eka Putri Al – As’ari Fani Nadila

FACULTY OF MEDICINE UNIVERSITY OF JAMBI 2019/2020

150

Introduction

The objective of Disaster Preparedness is to ensure that appropriate systems are in place and

Indonesia has reported as the top five countries

personnel are trained to provide immediate

that are most frequently hit by natural disasters

response to victims in the event of any

(Below, 2016). That is why Indonesia has called

Disaster. . The success or failure of any

as a “Supermarket of Disaster” (Wilopo, 2017).

Disaster Management operations will depend to

The Tsunami of Aceh in 2004 actually has

a great extent on the success achieved by the

awakened and alerted people of Indonesia the

Medical and Health sector since most of the

necessary of Disaster Preparedness (Wilopo,

Deaths and illnesses caused by disasters are

2017). Because the effects of disasters not only

preventable health risks. Though Disaster

caused death, but also social breakdown and

Management is the responsibility of every

even potentially causing a big health issue and

organization

epidemic

Sector has a key role to play, as it is the lead

(Machmud,

2019).

Hence,

and

institution,

the

Health

sector (Mulam, 2011).

community is immune from disasters (Barrimah, Issam et al, 2016)

Nonetheless, most of the physicians have never

The increase in natural disasters occurring

received well education and training on this field

places Emergency Medicine (EM) physicians at

(Wilopo, 2017). Historically, medical students

the forefront of responding to these crises (Sarin,

have been deployed to care for disaster victims

2017). After the Great Tsunami of Aceh,

but may not have been properly educated to do

government of Indonesia has put intention on

so (Mortelmans, 2016)..In some place, despite

Disaster

the

the increased scale and frequency of disasters,

regulation that they then soon made after the

limited attention has been made to identify and

events, which is Undang Undang no 24 tahun

list the disaster management related

2007. In the law, there is mentioned that one of

competencies

the priority is to “Save more Lives”, and as the

professional. The situation is further precarious

executor of this goal is the Health workforce,

with

include physicians. Plus, though it’s not entirely

students as nothing

true, in general, civilians mostly assume that

systematic manner that enables them to meet

hospital is like a shelter, and doctors take a lead

disaster

on disaster management (Wilopo, 2017). Hence,

competencies

Medical response is one of the most critical,

graduation from health professional schools

most important and of immediate requirement in

and universities (Swathi, et al, 2017). Disaster

any Disaster situation (Mulam, 2011).

medical topics may even be considered less

Preparedness,

reflected

151

regard

and to

and

skills for the health

medical/health

management

core

has

profession

been done in a

related standards

occupational upon

their

relevant (Parrillo, Steven J. et al, 2016). Disaster

practical feasibility needs to be further explored

medicine education in medical curricula is

(Barrimah, Issam et al, 2016).

scarce and frequently absent (Mortelmans et al.,

2016).

this

study,

would

present

some

educational approaches and teaching method of

One problem that might cause this is Emergency

Disaster Medicine that has occurred. Hopefully,

Medicine has some baseline recommendations

this study can trigger and be a start point of

for education in Disaster Medicine, but the

Disaster Medicine occurrence in Medical Study

physician training in disaster medicine and

in Indonesia. We strongly suggest this, and hope

response is currently not standardized or

our study can help and used as reference.

required for any physician training programs

Material and Method

(Sarin, 2017) Including in Indonesia. Only few University in Indonesia decided to arrange specific

curricula

for

Disaster

Study Design

Medicine.

This study is a systematic review of publications

(Universitas Syah Kuala, 2017)

relating to strategies for Disaster Medicine

From this background, we can conclude that, in

Education. In addition, a grey-literature manual

disaster events, physician has always become the

search was conducted to identify existing

stool on helping the civilian, and it is necessary

competency sets published on the websites of

and clearly needed to include Disaster Medicine

relevant

Education

organizations

the

Physicians

education,

universities, (GOs),

governmental nongovernmental

especially in Indonesia (Wilopo, 2017). Because

organizations (NGOs), and other professional

every medical student will one day be a

entities, performed as additional references.

physician who could face a disaster situation.

Data Collection

Accordingly, medical schools should embrace further disaster education at the medical student

The search was conducted on few reliable search

level. The natural events in the recent past have

engine and sources, such as PubMed, Cambridge

taught us that preparation is the key to a

Core, and Google Scholar. The

successful outcome. The community as a whole

restricted to title, abstract, and key words

depends on physicians and other health care

and search themes were combined using the

professionals to be ready to provide the highest

Boolean operator “AND” and “OR.”

caliber health care, regardless of the situation

was

TI = (Medical *OR Medical student*) AND TI

(Parrillo, Steven J. et al, 2016). Thus, Disaster

= (training *OR curriculum *OR education*)

medicine education for medical students is

AND TI = (Disaster *OR Disaster Medicine*)

recommended, while the applicability and

152

Data Selection

Further, we assest according the title, we take studies with relevant title. Then, we do a full text

For, initial search the inclusion criteria used in

assessment on each of them and extract them to

this review are (1) Studies that put (any kind of)

few selected papers that we consider relevant to

Disaster Medicine teaching approaches as their

our study. In final, we concluded 26 literatures

topic, (2) Studies that written in the last five

to be used in this study. To be more clear, we

years ( 2015-2019), (3) Paper that is written in

put the selection process in Diagram 1.

English, (4) a free access paper. Initial Search Result with the criteria

â&#x20AC;˘ Identification

(n = 836)

1st assesment (n = 72)

â&#x20AC;˘ Screening and Elegibility : Duplicates, Exlusion because of Title and abstract 2nd assesment ( n = 26)

â&#x20AC;˘ inclusion : after a fulltext assesment

Diagram 1 Review Selection Process and Result

Thematic analysis

Result

The selected literatures then analyze through the

The Selected Studies and their thematic result

thematic analysis were opted by research team in

will be explained in table 1 and table 2. Table 1

this study

describes the literature, and table 2 content the thematic analysis.

153

Table 1 Description of the Literature Author

Title

Country

Year

Methodology

Data Collecting Population tools

Sarin, Ritu R.

Disaster Education: A Survey

United

et al

Study to Analyze Disaster

States

2017

Medicine Training in Emergency

Analytic; Analyze

Questionnaire,

EM (Emergency

by Descriptive

distributed

Residency) residency

Statics

online

Program Directors in the

Medicine Residency Programs in

United States

the United States Camacho,

Education and Training of

N.D

Nieves Amat

Emergency Medical Teams:

PubMed,

et al

Recommendations for a Global

Google Scholar,

Operational Learning Framework

EMBASE

Swathi,

Disaster Management and Primary

Spain

Javeria

Health Care: Implications for

Majeed et al

Medical Education

Issam

Disaster Medicine Education for

Saudi

Barrimah, et al

Medical Students: Is It a Real

Arabia

2016

2017

Literature review

Search engine :

N.D

Health Profession Students

2017

Mixed quantitative

Questionnaire

and qualitative

Need?

Medical Students and teaching staffs

study (Cross-sectional Study)

Prihatiningsih,

A lesson learnt: Implementation of

Titi Savitri et al

Indonesia

2017

A randomized,

Clinical Test

Health Program Students

Interprofessional Education In

controlled trial

Score

(Medicine, Nursing, and

Disaster Management at Faculty of

using descriptive

(quantitative)

Health and Nutrition

154

Medicine Universitas Gadjah

mixed-method

and Log book &

Mada,Indonesia

analysis

Focus group

Program)

discussion (qualitative) Mark X.

60 Seconds to Survival: A

United

Cicero, Mark

Multisite Study of a Screen-based

States

X et al

Simulation to Improve Pre-hospital

2017

Prospective cohort

Score from

Emergency Medical

study

performed

Service Personel

assessment

Providers Disaster Triage Skills a prospective cohort study of a screen-based simulation intervention Madelina

An Emergency and Disaster

Ariani,

Course on Responding to

Madelina et al

Community and Family Healthcare

Indonesia

2019

Action Research

Clinical test as

Health Program Students

feedback

(Medicine, Nursing, and Public Health Program)

Problems with Interprofessional Education for Undergraduate Medical, Nursing, and Dietitian Students Hu, Hai

Application of Game-Based

China

2019

Learning in the Teaching Process

Prospective cohort study

of Disaster Medicine for Medical Student

155

Questionnaire

Medical Students

Drees, Simon

Crisis On the Game boardâ&#x20AC;&#x201C; a

et al

German

Action Research,

Paper-based

Novel Approach to Teach Medical

quantitative

evaluation

Students About Disaster Medicine

analysis German

2018

Maj, David

Deployment and Disaster

2018

Alexander

Medicine in an Undergraduate

Descriptive Statics

Back et al

Teaching Module

Analysis

Molloy,

Developing an Educational

United

Michael et al

Strategy for Delivering an E-

States

2019

Action Research;

Action Research

Medical Students

Pre & Post-test

Medical Students

Assessment and

Medical Students

feedback

learning Disaster Medicine Course for Undergraduate Students in US Medical Schools Takeda, Taichi

Development and Application of

Japan

2017

Action Research

Questionnaire

Medical Professional

2015

Action Research

Pre & Post-test,

Medical Students

an Educational Programfor Medical Disaster Health Coordinators in an Earthquakeand Tsunami Prone Area of Japan Mohamed-

Disaster dayâ&#x20AC;&#x2122;: Global Health

United

Ahmed, Rayan

Simulation Teaching

Kingdom

Wiesner,

Disaster Training In 24 Hours:

United

Lauren et al

Evaluation Of A Novel Medical

States

written feedback

et al 2017

Cohort Study

Questionnaire and evaluated

Student Curriculum In Disaster

using a paired t-

Medicine

test

156

Medical Students

Ragazzoni,

DisasterSISM: A Multi-Level

Luca et al

Blended Learning Program in

Italy

2019

Action Research

Pre & Post-Test

Medical Students

Brazil

2016

Action Research;

Pre & Post-Test

Medical Students

Disaster Medicine for Medical Students SimĂľes,

Education on Advanced Disaster

Romeo L et a

Medical Response ADMR Initial

Statistical Analysis

Experience in Brazil1 Afzali,

Full-scale Simulation May Be

Monika and

Used to Train Medical Students in

Sandra

Disaster Medicine

Denmark

2015

Action Research

Report on event

Medical Students

2017

Action Research

Survey, t-test

Medical Student

2017

Action Research

Report on event

Medical Students

Viggers Owens, Matt P

The South Dakota Model: Health

United

et al

Care Professions Student Disaster

States

Preparedness and Deployment Training Scott, Lancer

No Cost Solutions to Performance-

United

Based Disaster Medical Education

States

Dorigaatti,

In-person and Telemedicine

Brazil

2018

Action Research

Pre & Post Test

Medical Students

Alcir Escocia

Course Models for Disaster

et al

Preparedness: a Comparative 2016

Action Research

Written

Medical Students

Analysis Ghory, Hina et

Introductory Emergency Medicine

United

Clinical Skills Course: A Daylong

States

Feedback

Course Introducing Preclinical

157

Medical Students to the Role of First Responders Livingston,

Simulated Disaster Day: Benefit

United

Laura L. MA

from Lessons Learned Through

States

et al

Years of Transformation from

2016

Action Research

Report on event

Medical Students

2019

Action Research

Post Test

Medical Students

Silos to Interprofessional Education Rivera,

The Use of Simulation Games and

United

Lourdes

Tabletop Exercises in Disaster

States

Rodriguez et

Preparedness Training of

Emergency Medicine Residents

Noh, Jinyoung

The Use of Table-Top Simulation

Republic of 2019

& Hyun

for Team Training in Disaster

Korea

Chung

Events 2019

Ali Ardalan et

Virtual Disaster Simulation Lesson

Learned from an International

(Residents)

Action Research

Pre & Post Test

Medical students

Iran

2015

Action Research

Report on event

Medical students

N.D

2016

Literature review

Search engine

Medical Students

Collaboration That Can Be Leveraged for Disaster Education in Iran â&#x20AC;&#x201C; PLOS Currents Disasters Khorram-

Education in Disaster

Manesh, Amir

Management: What Do We Need?

et al

Proposing a New Global Program *N.D = No Data

158

Table 2 Thematic Analysis Title

Analysis

Disaster Education: A Survey Study to Analyze Technique/ teaching approach : (most common) drills, lectures, seminars, (less common) to Disaster

Medicine

Training

Emergency workshop, courses, tabletop exercises, and additional educational methods of self-reported

Medicine Residency Programs in the United States Education and Training of Emergency Medical Technique / teaching approach : theory-based lectures and discussions, to case-scenario Teams: Recommendations for a Global Operational exercises and simulations Learning Framework Important Point : There is 5 Point that should be learn as an Emergency Team Member : 1. From Theory to Practice 2. From Individual to Team Learning 3. Just-in-time Training 4. Skill Mix and Team Composition 5. Need to complete all level of training Disaster Management and Primary Health Care:

Technique / teaching approach : web-based training program

Implications for Medical Education Important Point : The listed competencies can be broadly categorized into three domains as 1. Disaster/Emergency Preparedness, Early Warning and Response system, 2. Patient care and Mass Casualty Management, and 3. Resource (human and material) Management and Eviction. Disaster Medicine Education for Medical Students:

Technique/ teaching approach : Lectures, Seminars, online web-based courses, video

159

Is It a Real Need?

conferencing, self-study booklets, newsletter, pamphlets, video, and audio tapes, clinical skills laboratory, video demonstration, drill Important Point : More than half of the participants selected ‘‘traditional classroom lectures/seminars,’’ and ‘‘online web-based courses’’ as their preferred teaching methods. However, they considered that video conferencing, self-study booklets with posttest, newsletters, pamphlets, video and audio tapes are not appropriate for teaching disaster medicine. Regarding teaching methods and materials, participants thought that clinical skills laboratory in College of Medicine could be a great asset for this course. Interviewees further added that the teaching strategies, such as video demonstration and participating in drills, will be of great value in their learning.

lesson

Interprofessional

learnt:

Implementation

Education

of Technique/ teaching approach :

Disaster a case study, expert lectures, independent learning, small group discussion with and without

Management at Faculty of Medicine Universitas tutors, laboratory skills and self-directed learning and assessments Gadjah Mada,Indonesia Important Point : Competencies that they put on the module, namely : 1. Understanding interprofessional practice through interpofessional education in the context of disaster management, 2. Understanding the impact of disasters on the provision of interprofessional health services, 3. Understanding the role and function of a medical doctor, a nurse and a dietician in a

160

health care system in the context of a disaster management, 4. Application

skills

interprofessional

practice

including

effective

interprofessional communication and leadership. 60 Seconds to Survival: A Multisite Study of a Technique/ teaching approach : screen-based simulation (video games) Screen-based Simulation to Improve Pre-hospital Providers Disaster Triage Skills a prospective Important Point: cohort

study

screen-based

simulation Screen-based simulations are defined by the Society for Simulation in Healthcare as

intervention

computer-generated video game simulators that create scenarios that require real-time decision making in a virtual environment. The ability to access these simulations or games on any device with access to the Internet enables low-cost, time-efficient, and generalizable standardized training. In other health care disciplines, video games have been shown to : 1. Improve procedural skills, 2. Have been associated with improvements in communication, and 3. Have yielded changes in risk taking behavior among patients Video games are a promising asynchronous learning modality for pre-hospital care providers acquiring and maintaining disaster triage skills. 60 Seconds to Survival is a viable means for learning and honing disaster triage.

An Emergency and Disaster Course on Responding Technique/ teaching approach : to Community and Family Healthcare Problems Mix method, between class lecture, training skill, and simulation. with

Interprofessional

Education

for

Undergraduate Medical, Nursing, and Dietitian Important Point : Students

The course goals are to 1. Educate students on disaster health management,

161

2. Understand the health preparedness and disaster family kit, and 3. Define the principle of health workerâ&#x20AC;&#x2122;s role and collaboration in disaster. The course was well received and at the 2017-2018 sessions was improved based on students and faculty feedback. Disaster knowledge of students changed. However, they still had a problem in communication between professions. And addition, they became aware of the function and each role of health profession competency during a disaster. Application of Game-Based Learning in the Technique/ teaching approach : a novel method, which is named Game-Based Learning Teaching Process of Disaster Medicine for Medical

(GBL)

Student Important Point : after attending a class about knowledge of injury classification with one board game adopted, most of the students believed GBL was better than traditional methods of teaching Crisis On the Game boardâ&#x20AC;&#x201C; a Novel Approach to Technique/ teaching : Seven workshops were facilitated between 4 October 2016 and Teach Medical Students About Disaster Medicine

December2017, on the workshops they used a board game named AFTERSHOCK Important Point: Board games such as AFTERSHOCK are well-suited for medical education and enjoy high rates of acceptance among students. To ensure deeper and longer-term learning, they should be accompanied by theoretical course work

Deployment

and

Disaster

Medicine

Undergraduate Teaching Module

an Technique/ teaching approach : 1. Seminars (29 hours, 40%) conveyed basic knowledge about the single topics as a basis for the other teaching formats. 2. Practical training (21 hours, 29%) focused on practical skills ranging from triage, surgical and anaesthesiological emergency procedures to experiences with barrier nursing.

162

3. Clinical case discussions (10 hours, 14%) built on seminars and covered diagnoses and therapies of different medical specialties by focusing on patient cases. 4. Group work (8 hours, 11%) was used to deepen coverage of controversial aspects from different perspectives and to discuss them extensively with the students (e.g., ethics). 5. e-Learning (4 hours, 6%) was integrated into triage simulations and psychological diagnostics. Additionally, a supplemental online course was offered via the medical school’s learning management system (Blackboard Inc. Washington, DC, USA), including literature, links to useful online sources like videos, self-produced podcasts (ABCDE, psychotrauma) and interactive X-ray patient cases Important point : Even though there are possibilities to train students in triage with computer simulations, we considered live exercises with their personal sensual impressions as irreplaceable for the students’ learning experience and for making the teaching contents easier to remember, which was supported by the participants Developing an Educational Strategy for Delivering Technique/ teaching approach : an E-learning Disaster Medicine Course for A novel apps and external online resources. The course focuses heavily on outcome-based Undergraduate Students in US Medical Schools

education with an emphasis on the development of applicable skills. Each lecture is divided into a series of learning objectives to allow students to master concepts sequentially, followed by questions to make use of the “testing effect”

Development and Application of an Educational Technique/ teaching approach : 4-hour programs, that includes 2-hour didactic lectures and Program for Medical Disaster Health Coordinators

2-hourtabletop exercise

in an Earthquake and Tsunami Prone Area of Japan

163

Disaster day’: Global Health Simulation Teaching

Technique/ teaching approach: Simulation- based teaching can provide students with ‘handson’ exposure.

Disaster Training In 24 Hours: Evaluation Of A Technique / teaching approach: 24 hours of training consisting of didactics and hands-on Novel Medical Student Curriculum In Disaster

exercises was delivered to medical students

Medicine Important Point: Core content areas for the curriculum include: 1. Mass casualty incidents and triage 2. Chemical, biological, radiological, nuclear, and high explosives threats 3. Incident command system and the National Incident Management System 4. Blast and burn injuries 5. Decontamination and use of personal protective equipment 6. Surge capacity and government response 7. Hospital preparedness and hazard vulnerability analyses 8. Legal and ethical considerations of disaster response DisasterSISM: A Multi-Level Blended Learning Technique/ teaching approach : e-learning, peer education, table-top exercises, and virtual Program in Disaster Medicine for Medical Students Education

Advanced

Disaster

reality simulations

Medical Technique/ teaching approach : 8 hours of lectures and exercises

Response ADMR Initial Experience in Brazil1 The principal aim is to reduce mortality in such situations, and this course improves the performance of teams when responding to multiple-victim incidents Full-scale Simulation May Be Used to Train Technique/ teaching approach : lectures, workshops, scenario, debriefing, simulations Medical Students in Disaster Medicine The South Dakota Model: Health Care Professions Technique/ teaching approach : lecture, hands-on small group activity

164

Student Disaster Preparedness and Deployment Training No Cost Solutions to Performance-Based Disaster Technique/ teaching approach : The course consisted of an online questionnaire, didactic Medical Education

lectures, small group exercises, and two live, multi-patient, mass-casualty incident (MCI)scenarios

In-person and Telemedicine Course Models for Technique/ teaching approach : lecture and videoconferencing Disaster Preparedness: a Comparative Analysis Introductory Emergency Medicine Clinical Skills

Technique teaching approach: lectures followed by related workshops. Students also practice

Course: A Daylong Course Introducing Preclinical

managing ill patients in multiple case scenarios and participate in a tabletop disaster-

Medical Students to the Role of First Responders

management exercise Important Point : Educational Objectives 1. Describe the role of the first responder 2. Perform basic emergency resuscitation 3. Perform many of the critical actions necessary for a first responder to manage an ill or injured patient in nonmedical settings with limited resources.

Simulated Disaster Day: Benefit from Lessons Technique/ teaching approach : Learned Through Years of Transformation from

Disaster Day consists of four phases: Planning, Team Building, Disaster Simulation, and

Silos to Interprofessional Education

Group Debriefing. Faculty and multidisciplinary student planning committees work for 10 months each year to organize the event. On simulation day, preselected health care teams consisting of students from all participating disciplines meet for team building sessions during which they establish a strategic plan for patient care. Licensed professionals from every profession represented in the student population are on site observing and guiding

165

students during the simulation. The Use of Simulation Games and Tabletop Technique/ teaching approach : traditional lecture-based instruction (LEC) and the second Exercises in Disaster Preparedness Training of

utilizing interactive simulation/game-based teaching (SIM)

Emergency Medicine Residents The Use of Table-Top Simulation for Team Technique/ teaching approach : lecture, table-top simulation, and debriefing Training in Disaster Events 2019 Virtual Disaster Simulation Lesson Learned from

Technique/ teaching approach : From 3rd to 6th January 2015, the TUMS in collaboration

an International Collaboration That Can Be with CRIMEDIM organized a training workshop on application of new technologies in Leveraged for Disaster Education in Iran â&#x20AC;&#x201C; PLOS disaster management simulation in Tehran (training workshop, simulation) Currents Disasters Education in Disaster Management: What Do We

Technique/ teaching approach : face to face lecture, skill station, practical exercises, video

Need? Proposing a New Global Program

lectured, Computer-mediated environment Simulation, table top simulation, real- time simulation

166

Discussion

Table 3 teaching approach on disaster medicine

Teaching approach

Drills

Lectures

Seminars

â&#x20AC;&#x153;traditionalâ&#x20AC;? method that has used for a long

Workshops

time in teaching. But then, there is a lot more

Tabletop Exercise

new method keep coming up and used as a new

Self-Reported, Independent

motivation in teaching, one of the method is

Learning, Self Directed Learning

simulation. Simulation is still rarely used

Group Discussion (debriefing)

because it still showed ineffective on most

Simulations, case study

subjects but proven very effective when it

Web-based

applied to disaster medicine. There are many

Clinical Laboratory skill

kind of simulation that has been developed.

Video Conferencing

Starting from real-situation simulation with real

Self -study with booklet,

people, virtual reality, and even video games

newspaper, etc.

that have proven giving a good impact on the

Video Demonstration

students and also fun. Significantly suppress

Simulation, Video Games

stress level that medical student usually have

Real Simulation

when learning.

Hands-on Exercises

Peer-Education

On table 3 we can see the teaching approaches of disaster medicine that has exist. From the table, Lecture is the most commonly applied method. This probably because lecture is a

Also there is peer-education

method where students can learn from each of them

and

develop

their

ability

between

themselves. I : Drills II : Lectures III : Seminars IV : Workshops V : Tabletop Exercise VI : Self-Reported, independent learning, self directed learning VII : Group Discussion (de briefing) VIII : Simulations, case study IX : Web-based X : Clinical Laboratory Skill XI : Video Conferencing XII : Self study With booklet, newspaper, etc XIII : Video Demonstration XIV : Simulation, video games XV : Real Simulation XVI : Hands-on Exercise XVII : Peer-Education

167

Also from the result we can conclude all the

Disaster

event

competencies that used in disaster medicine. The

physicians

competencies are:

Calculating risk with precision is a must.

frequently take

tough

required decisions.

10. Complete training

1. Early response, fast response (just-in-time-

11. Health disaster management

learning)

Many diseases usually appearing between

Time is a vital factors especially for life

the disaster refugee, and this situation will

saving. In disaster event, it almost certain

required health disaster management

that a lot of people will injure. A fast

12. Skill on disaster family kit

response is required to prevent things get

13. Registering and dispatching medical teams

worsen.

14. Analyzing

2. Mass casualty management

and

assessing

situations

(vulnerability analysis)

In disaster event, injured people can increase

15. Triage

up to thousands people. Mass casualty

16. Incident command system and national

management would be required to face this

incident management system

situation.

17. Hospital Preparedness

3. Resource management

18. Legal and ethical considerations of disaster

Resources will be limited in disaster event, so resource management is required.

All of those competencies are highly needed in

4. Each role on team (team composition)

disaster situation and usually will not be

There will be multi profession working in

received in usual emergency medicine.

disaster event therefore understanding on

Conclusion

each role is needed 5. Leadership

Physicians should consider their potential roles

In facing disaster event, we will be on team.

in a disaster and attempt to prepare his role in

Oftentimes physicians will take the lead.

disaster. Disasters are unpredictable. Preparation

6. Work on team

is vitally important. Disaster training and

7. Effective communication

exercises can help physicians plan for and

8. Procedural skill (from theory to practice)

successfully respond to the next natural disaster.

Oftentimes, physicians has learnt the theory

Indonesia is located in a disaster-prone area, and

of emergency, in fact physicians also need to

natural disaster event frequent even keep

practice to get skilled in field.

increasing from time to time and oftentimes

9. Changes in risk taking behavior

causing a large casualty. Physicians take the lead role on saving life in disaster event. Every

168

physician decision making, time taking, and act

management on the medicine curriculum. We

on responding is vital and thousand people and

hereby present references of teaching approach

victim depend on it. So, it should be realize that

and competencies of Disaster Medicine that has

disaster medicine is a necessity.

exist all over the world So doctor can act on his maximal capability in disaster event. In the end,

We strongly suggest for all medical faculty in

we hope all future doctors in Indonesia got the

Indonesia to teach disaster medicine and prepare

best education to help to improve welfare in

all the future doctor in Indonesia for facing the

Indonesia.

unpredictable event such natural disaster. Also we suggestion to put disaster medicine and

169

Appendix Barrimah, Issam et al. (2016). Disaster medicine education for medicalstudents: Is it a real need? Medical Teacher, 60. Below, R. et al. (2016). Annual DisasterStatistical Review 2016. Centre for Research on the Epidemiology of Disasters. Machmud, R. (2019). Peran Petugas Kesehatan Dalam Penanggulangan Bencana Alam. Mortelmans, L. J, et al. (2016). Are Belgian military students in medical sciencesbetter educated in disaster medicine than theircivilian colleagues? CrossMark, 383-386. Mulam, B, et al. (2011). Emergency Medical Preparedness for Disaster Risk Reduction: The Role of Health Sector Personnel - An Overview. Prehospital and Disaster Medicine. Parrillo, Steven J. et al. (2016). A Survey of Disaster Medical Education inOsteopathic Medical School Curricula. Prehospital and Disaster Medicine. Sarin, R. R et al. (2017). Disaster Education: A Survey Study to AnalyzeDisaster Medicine Training in EmergencyMedicine Residency Programs in the United States. Prehospital and Disaster Medicine. Swathi, et al. (2017). Disaster management and primary health care: implications for medical education. International Journal of Medical Education, 414-415. Undang Undang no 24 tahun 2007. Universitas Syah Kuala. (2017). Mendidik Dokter Agar Memahami Bencana. Wilopo, S. A. (2017). Kompetensi Inti untuk Kedokteran Bencana dan Kesehatan Masyarakat: Proposal untuk revisi Standard Kompetensi Dokter Indonesia tahun 2017. Pekan Ilmiah Tahunan & Rakernas 2017- PDK3M. Banda Aceh.

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PCC EAMSC 2019

Practice of Interprofessional Education as Health Provider in Emergency of Natural Disaster Nadia K. S. Pavita,1 Farida Aisyah1 1

Second Year of Medical Student, University of Sebelas Maret Surakarta [corresponding email: nadiakirana34@gmail.com] Abstract

Indonesia is a country that has geographical, geological, hydrological, and demographic conditions that enable to get natural disasters, whether caused by natural factors, non-natural factors, and human factors that have an impact on fatalities, natural damage, property losses, and psychological impacts, this condition making Indonesia as one of country with high emergency situation, this situation followed by poor emergency rescue team. As health provider whose one of emergency team, practice interprofessional education could be the solution of this system. Interprofessional education can be applied by health providers in disaster management because interprofessional education regulates how every profession works according to its role and function, so there is no overlapping role and patient health due to disaster can be optimal Keyword: interprofessional education, Indonesia, natural disaster, emergency, health provider

171

Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference (PCC EAMSC) 2020 India

Scientific Paper

Practice of Interprofessional Education as Health Provider in Emergency of Natural Disaster

By Nadia K. S. Pavita

(G0018149)

Farida Aisyah

(G0018071)

172

Practice of Interprofessional Education as Health Provider in Emergency of Natural Disaster

Introduction Indonesia is a country that has geographical, geological, hydrological, and demographic conditions that enable to get natural disasters, whether caused by natural factors, non-natural factors, and human factors that have an impact on fatalities, natural damage, property losses, and psychological impacts. In 2018, Indonesia experienced various natural disasters, such as the Lebak-Banten Earthquake, the Brebes Landslide, the Mount Sinabung Eruption, the Lombok Earthquake, and the Palu Earthquake and Tsunami. The National Disaster Management Agency (BNPB) noted that in the 2018 period there were 679 floods, 473 lands landslides, 34 abrasions, 804 tornadoes, 129 droughts, 370 forest and land fires, 21 earthquakes, 58 volcanic eruptions, 21 earthquakes, 1 tsunami, and 1 earthquake followed by a tsunami. These types of disasters can cause health crises such as the emergence of food and nutrition problems, the problem of availability of clean water, environmental sanitation problems, paralysis of health services, the emergence of post-stress cases trauma, increased potential for infectious or non-communicable diseases, and scarcity of health workers.

Figure 1. BNPB data on the number of victims and injuries period 2018 (Banjir = Flood, Tanah Longsor = landslide, Gelombang Air Pasang = Tidal Wave, Putih Beliung = White Pickaxe, Kekeringan = Drought, Kebakaran Hutan dan Lahan = Forest and Land Fire, Gempa Bumi = Earthquake, Letusan Gunung Api = Volcano Eruption, Kejadian = Incident, Meninggal = Death, Luka-luka = injury)

173

Based on the Law of Republic Indonesia, Number 24 Year 2007 concerning about Disaster Management, â&#x20AC;&#x153;the management of disaster management is a series of efforts which include the establishment of development policies that risk the occurrence of disasters, disaster prevention activities, emergency response, and rehabilitation.â&#x20AC;? Management of health problems in disaster conditions is indicated to ensure the delivery of health services for victims of disasters and refugees according to minimum standards. To minimize the impact of natural disasters, health providers play a significant role. All health provider efforts carried out in the context of prevention, mitigation, preparedness, emergency response, and recovery related with disasters carried out before, during and after disasters that are designed to provide a framework for individuals or communities who are at risk of disaster to avoid, control risk, reduce, manage and recover themselves from the effects of disaster. Health providers consist of consultants, doctors, specialist doctors, physiotherapists, midwives, nurses, pharmacists, psychologists and public health. Each health provider must have knowledge in accordance with their respective fields and the ability to work quickly, accurately, and well as a team. Aside from health providers as health human resources, they also need to know more about disaster management, including pre-disaster and post-disaster activities. Disaster conditions that require all elements of society to move quickly, especially health providers, requiring every health provider profession must focus on patients or patient center care. In patient center care, patients are the decision holders for each examination or medical action that will be given to them. If there are cases, where the patient is unconscious or something else, the family can be the patient's representative in making decisions. All actions taken by the health provider focus on the recovery of the patient, but the health provider does not only consist of one profession, but a variety of professions in one area of health, it is necessary to collaborate health providers so that patient recovery can be carried out efficiently. Collaboration of each health provider implemented based on interprofessional education. Interprofessional education occurs when two or more professions learn together to improve collaboration and service quality. Collaboration between professions is defined as a process that includes communication, decision making, and synergizing the abilities and knowledge of each profession as a team. Based on the location of Indonesia which is prone to natural disasters and the importance of collaboration between health providers to minimize the impact of natural disasters, the authors have the idea to apply the practice of interprofessional education as a health provider in the framework of natural disaster management. Interprofessional Education

174

Interprofessional education can be defined as joint learning activities carried out by two or more professions with the aim of strengthening collaborative practice. According to WHO, interprofessional education can be defined as experiences that occur when students from two or more professions learn about, from, and with each other as opportunities where two or more professions learn together. Definitions of interprofessional education are very diverse, therefore there are several aspects that must be present in the implementation and definition of interprofessional education, such us: 1) Active involvement by two or more health providers in the context of patient management; 2) The process of socializing and learning based on practice; 3) The process in which students learn with, from, and about one another, both in and across disciplines; 4) andragogical (nonhierarchical and de-centered); 5) The process of sharing knowledge and values; 6) Collaboration in patient centered care with the goal of optimizing patient health. 16 The goals of interprofessional education are to learn how each profession plays a role in an interprofessional team and to increase knowledge, skills and values in future work practices that ultimately provide later health services to patients as part of a collaborative interprofessional team. Broadly speaking about it, interprofessional education is expected to increase interprofessional collaboration where in the future interprofessional collaboration will improve the quality of health. Health Provider Health providers or health practitioners are defined as individuals or groups of people who provide health care services. Health providers consist of several types, such us: 1) Primary Care, a person who is first encountered by patients for checkups and health problems; 2) Nursing Care; 3) Drug Therapy, is a pharmacist who has been licensed and passed the specified minimum education level; 4) Specialty Care, primary care providers can refer patients to more professional health providers, namely specialty care, in a variety of specialties when needed. Health providers consist of general practitioners, specialists, dentists, assistant

physicians,

osteopathy,

podiatrists,

chiropractors,

pharmacists,

nutritionists,

clinical

psychologists, nurses, neonatal nurses who have been certified, midwives, physical therapy, physician assistants, occupational therapists, paramedics, and clinical social workers who have been given authority.

175

Figure 2. The operational term relates to interprofessional education

Disaster management Based on the Law of Republic Indonesia Number 24 Year 2007 concerning Disaster Management, the implementation of disaster management is a series of efforts that include the establishment of development policies that are at risk of disaster, disaster prevention activities, emergency response, and rehabilitation. Disaster management always develops over time and one place with another is different in how to deal with it, disaster becomes a joint matter with the government being the main responsible. One of the principles of disaster management is coordination and integration, coordination is defined as disaster management based on good coordination and mutual support and integration is interpreted as disaster management carried out by various sectors in an integrated manner based on good and supportive cooperation. Health providers have an obligation to deal with patients due to natural disasters. In the event of a disaster there needs to be mobilization of health providers who are members of a Crisis Management Team which includes: 1) Rapid Reaction Team; 2) Rapid Assessment Team (Rapid Health Assessment Team); 3) Health Assistance Team. The Rapid Reaction Team is a team that is expected to immediately move within 0-24 hours after there is information about a disaster event, this team consists of: 1 sanitarian, 1 communication officer, and medical service consisting of: 1 general practitioner, 1 surgeon, 1 anesthetist, 2 nurses, 1 disaster victim identification staff, 1 pharmacist or pharmacist assistant, and 1 ambulance driver. The Rapid Assessment Team is a team that can be dispatched simultaneously with the Rapid Response Team or follow up in less than 24 hours, this team consists of: 1 general practitioner, 1 epidemiologist, and 1 sanitarian. The Health Assistance Team is a team dispatched based on needs after the Rapid Reaction

176

Team and the Rapid Assessment Team returned with reports on the results of their activities in the field, this team consisted of: general practitioners, pharmacists and pharmacist assistants, nurses, midwives, sanitarians, nutritionists, surveillance personnel, and entomologists. The involvement of many parties in disaster management presents challenges of coordination, lack of coordination often results in humanitarian assistance not reaching the people who need it. The role of each element needs to be coordinated and communicated, so that the implementation of disaster management can actively involve all elements and does not result in overlapping roles. Communication helps health providers in collaborative practice to work together to start an effective interprofessional collaboration. Coordination in the distribution of health providers with certain roles and functions during a crisis period are important components of an emergency preparedness plan. Interprofessional education is an important step in preparing health providers to work collaboratively to anticipate the various effects of natural disasters so that patients recovery gets better. Interprofessioanl education has a team-based learning model that can be opportunities for health providers to build relationships with patients, families, and other health providers. In our conditions of natural disasters, where patients are the main focus, effective teamwork is an important competency in interprofessional education. Ineffective team performance can result in the handling of patients that are nonoptimal, so it is necessary to apply collaborative practices by health providers in dealing with emergencies in order to produce better patient recovery, this is also influenced by adequate knowledge and skills according to the role of each profession by each profession in the team as well as communication skills well. Interprofessional education is an important subject in preparing graduates of the health profession for interprofessional collaboration with the aim of resolving health problems or illnesses caused by natural disasters. Every health provider, beside must have essential and communication skills, they need to develop a spirit of mutual respect, trust, and collaborative work in a synergistic effort to take quick, accurate, and appropriate actions so that the health of disaster victims can be achieved. Conclusions and suggestions Disaster management involves many parties from various professions, especially from a health background. Interprofessional education can be applied by health providers in disaster management because interprofessional education regulates how every profession works according to its role and function, so there is no overlapping role and patient health due to disaster can be optimal. References American Association of Colleges of Nursing, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, American Dental Education Association,

177

Association of American Medical Colleges, Association of Schools of Public Health (2011). Core Competencies for Interprofessional Collaborative Practice. Interprofessional Education Collaborative Expert Panel. National Disaster Team Rescue (2014). Rencana Nasional Penanggulangan Bencana 2015-2019. Badan Nasional Penanggulangan Bencana. National Disaster Team Rescue (2018). Bencana Alam di Indonesia Tahun 2018 s/d 2018. http://bnpb.cloud/dibi/grafik1a â&#x20AC;&#x201C;accessed on September 2019 Berkeley

Human

Resources.

Who

Considered

Health

Care

Provider/Practitioner.

https://hr.berkeley.edu/node/3777 - accessed on September 2019 Cahya Saraswati. Penerapan Kurikulum Interprofessional Education (IPE) Sebagai Dasar Awal Terbentuknya Interprofessional Collaboration di Indonesia. Universitas Udayana. Centra

Care

Health.

Definitions

Health

Care

Provider

Credentials.

https://www.centracare.com/providers/definitions-of-health-care-provider-credentials/

-accessed

on September 2019 Charles Engel and Lonica Vanclay (1997). Towards Audit and Outcome Evaluation of Interprofessional Education for Collaboration in Primary Health Care. The UK Centre For The Advancement of Interprofessional Education. Diane R. Bridges, Richard A. Davidson, Peggy Soule Odegard, Ian V. Maki, John Tomkowiak. Interprofessional Collaboration: Three Best Practice Models of Interprofessional Education. Medical Education Online. 2011; 16(1): 6035. Dwiky

Wijaya

(2018).

Interprofessional

Education

dan

Interprofessional

Collaboration.

https://www.scribd.com/document/391560459/Interprofessional-Education-DanInterprofessional-Collaboration#logout -accessed on September 2019 Gubernur Sumatera Barat. 2007. Peraturan Daerah No. 5 Tahun 2007 tentang Penanggulangan Bencana. Lembaran Daerah Provinsi Sumatera Barat Tahun 2007, No.5. Padang. Health Professions Networks Nursing and Midwifery Human Resources for Health (2010). Framework for Action on Interprofessional Education and Collaborative Practice. World Health Organization.

178

Hugh Barr, Marion Helme, Lynda Dâ&#x20AC;&#x2122;Avray (2011). Developing Interprofessional Education in Health and Social Care Courses in the United Kingdom A Progress Report. Health Sciences and Practice Subject Centre Higher Education Academy. Lincoln Chen, David Evans, Tim Evans, Ratu Sadana, Barbara Stilwet, Phyllida travis, Wim V. Lerberghe, et al (2006). Working Together for Health. World Health Organization. Linda J. Vorvick (2018). Types of Health Care Providers. https://medlineplus.gov/ency/article/001933.htm -accessed on September 2019 Maria Olenick, Lois R. Allen, Raymon A. Smego Jr. Interprofessional Education: A Concept Analysis. Dove Press Journal: Advances in Medical Education and Practice. 2010; 1: 75-84. Meutia Faradilla. Peran Tenaga Kefarmasian dalam Penanggulangan Bencana. Pharmaceutical Sciences and Research. 2018; 5(1): 14-18. Mudjiharto, Lucky T., Els M., Yus R., Muhammad I. S. H., Indro M., Edy S., et al (2011). Pedoman Teknis Penanggulangan Krisis Kesehatan Akibat Bencana. Badan Nasional Penanggulangan Bencana. Nizwardi Azkha. Peranan Petugas Kesehatan dalam Penanggulangan Bencana. Jurnal Kesehatan Masyarakat. 2009; 4(1). doi: 10.24893/jkma.4.1.1-4.2009. NLN Board of Governors (2015). Interprofessional Collaboration in Education and Practice. NLN Vision Series. Ova E., Rossi S., Adi H. S., Wahyudi I., Yayi S. P., Fatwasari T. D., Mariyono S., et al (2014). Buku Acuan Umum CFHC-IPE. Fakultas Kedokteran Universitas Gadjah Mada Yogyakarta. Putri Rahayu (2018). 5 Bencana Alam Indonesia yang Menyita Perhatian Publik di Tahun 2018. https://www.idntimes.com/news/indonesia/putri-rahayu-2/5-bencana-alam-indonesia-2018c1c2/full -accessed on September 2019 Republik Indonesia. 2007. Undang-Undang No. 24 Tahun 2007 tentang Penanggulangan Bencana. Lembaran Negara RI Tahun 2007, No. 66. Jakarta. Rizanda Machmud. Peran Petugas Kesehatan dalam Penanggulangan Bencana Alam. Jurnal Kesehatan Masyarakat. 2008; 3(1): 28-34. Shauna M. Buring, Alok Bhushan, Amy Broeseker, Susan Conway, Wendy Duncan-Hewitt, Laura Hansen, Saran Westberg. Interprofessional Education: Definition, Student Competencies, and Guidelines for Implementation. American Journal of Pharmaceutical Education. 2009; 73(4): Article 59.

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Steviyanti Tatuil., Chreisye K. F. Mandagi, Sulaemana Engkeng. Kajian Peran Tenaga Kesehatan dalam Kesiapsiagaan Bencana Banjir di Wilayah Kerja Puskesmas Tuminting Kota Manado. Ejournalhealth. 2017; 9(3). Sutopo P. Nugroho (2016). Manajemen Bencana di Indonesia. Badan Nasional Penanggulangan Bencana Wharton High School (2013). Health Care Provider. http://kwhs.wharton.upenn.edu/term/health-careprovider/ -accessed on September 2019 Widayatun and Zainal Fatoni. Permasalahan Kesehatan dalam Kondisi Bencana: Peran Petugas Kesehatan dan Partisipasi Masyarakat. Jurnal Kependudukan Indonesia. 2013; 8(1): 37-52. Wiwik Kusumawati. Natural Disaster and Interprofessional Education. PharmaŇŤiana. 2015; 5(1): 93-100.

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More Than Just a Game? The Effectiveness of Virtual Reality Exposure Therapy for PostTraumatic Stress Disoreder (PTSD) in Psychiatric Emergency Setting: A Systematic Review and Meta analysis Ahmad Taufik Fadillah Zainal1), Arief Abdurrazaq Dharma1), Indah Nurul Khairunnisa1), Andi Jihan Nashila Haris1) 1)

Universitas Hasanuddin ABSTRACT

Aim: This study was aimed to compare the effectiveness between Cognitive Brain Therapy and Virtual Reality Exposure for treating PTSD Introduction: Suicidality correlates with decision-making circuits in PTSD patients. With the high prevalence of PTSD (ranged from 11.3% to 60.2% in South Asia and Southeast Asia), the need for treatment for PTSD is crucial. Along with the growth of technology, many inventions are made and potentially useful for medical purposes, even for treating psychiatric patients. A kind of prolonged exposure therapy to treat patients with PTSD is using virtual reality (VR) technology, known as virtual reality exposure therapy (VRET). In this systematic review, recommendations for how to incorporate VR into psychiatric care, and future directions for VR based treatment and clinical research. Material and Method: This systematic review is based on Preferred Reporting Items for Systematic Review and Meta-Analysis statement (PRISMA) and was organized adhering to previously recommended guidelines for transparent and comprehensive reporting of methodology and result. Data from each journal is collected. If there is incomplete data, the researcher contacted his authors by e-mail to retrieve the data, and if they did not provide a response then the studies were excluded. All analysis were conducted by Review Manager 5.3. The researcher carried out a meta-analysis by including the mean CAPS Post-treatment of several domains that met the criteria for quantitative analysis. Result: We compared the pooled effect size of VRET on PTSD to control conditions in a fix-effects model. Moderate pooled effect size was observed (4 studies, n=339, z=1.26, 95% CI: -2.08â&#x20AC;&#x201C;9.60, p=0.21) (see Fig.

181

3 for the forest plot). The result shows that Cognitive Behavior Therapy (CBT) tends to be more effective compared to Virtual Reality Exposure Therapy (VRET) although with a low significance (p=0.21). Conclusion: VRET is not significantly effective as a treatment for PTSD compared to CBT. Although it is not better than conventional therapies, VRET is worth to be combined with CBT. The main target of CBT is to correct patientâ&#x20AC;&#x2122;s cognitive behavior. Keywords: Virtual Reality Exposure Therapy (VRET), Post-Traumatic Stress Disorder (PTSD), Cognitive Behavior Therapy (CBT)

182

More Than Just a Game? The Effectiveness of Virtual Reality Exposure Therapy for Post-Traumatic Stress Disoreder (PTSD) in Psychiatric Emergency Setting: A Systematic Review and Meta analysis Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2020

By: Ahmad Taufik Fadillah Zainal Arief Abdurrazaq Dharma Indah Nurul Khairunnisa Andi Jihan Nashila Haris

Faculty of Medicine Hasanuddin University Makassar 2019

183

Exposure therapy targets behaviors that patients

Introduction Post-traumatic stress disorder (PTSD) is a chronic

engage in (most often avoidance) in response to

psychiatric disorder, caused by the exposure of

situations or thoughts and memories that are

traumatic events, such as war, sexual assault, natural

considered as frightening or anxiety-provoking. And

disaster, or serious accident. PTSD patients may

for exposure therapy to be effective, it is very

suffer depression, anxiety, shame, guilt and reduced

important that a person faces a situation that closely

libido, which contribute to their distress and affect as

resembles what they fear most. However, this may

a life threatening. According to a trial by Barredo et

not always be possible for the person with PTSD. For

al. through potential suicidality biomarkers in

example, a veteran who developed PTSD as a result

neuroimaging, it showed that suicidality correlated

of combat exposure would not be able to face a

with decision-making circuits in patients with PTSD

combat situation again (Beidel et al., 2019).

(Barredo et al., 2019) and can lead to potentially fatal

Thus, with the growth of technology, many inventions are made and potentially useful for

disorder, suicide. Mental health status of the population in developed countries is often ignored or underdiagnosed, along with very low awareness among healthcare providers. In South Asia and Southeast Asia where a very few studies conducted in were undertaken to study consequences of specific traumatic event, such as a natural disaster like a hurricane/tsunami or after a man-made disaster like factory fire or collapse with a prevalence ranged from 11.3% to 60.2% (Arnberg, Bergh Johannesson, & Michel, 2013; Fitch, Villanueva, Quadir, Sagiraju, & Alamgir, 2015). Thus, the need for treatment of PTSD is crucial.

medical purposes, even for treating psychiatric patients. A kind of prolonged exposure therapy to treat patients with PTSD is using virtual reality (VR) technology, known as Virtual Reality Exposure Therapy (VRET). Virtual reality allows users interact with the environment from an egocentric point of view or an allocentric point of view, in very near real time, depending on the type of system and programming. Users may also act upon virtual objects shown, and even virtual beings. Users can interact via his own movements by wearing at least one input device (known as "tracker") in more immerse egocentric VR systems (Baus & Bouchard, 2014). Combination of

Exposure therapy is considered to be a

computer simulations of sights, sounds, vibrations

behavioral treatment for PTSD, such as cognitive

and smells patched to the patient's individual trauma,

behavior therapy (CBT), cognitive procedural

integrates real time computer graphics with multiple

therapy (CPT), eye movement desensitization and

sensory cues in order to create an evocative

reprocessing (EMDR), and prolonged group therapy.

environment

However, despite an abundance of evidence pointing

imaginative exposure with visual, auditory, olfactory,

to the effectiveness, there is a major disadvantage of

and haptic computer-generated experiences (Gerardi,

traditional therapies. The subjects stated that it is

Cukor, Difede, Rizzo, & Rothbaum, 2010; Gerardi,

difficult to fully immerse in the traumatic scene and

Rothbaum, Ressler, Heekin, & Rizzo, 2008).

that

may

augment

patient's

the treatment of traditional exposure therapy

In this systematic review, we compare the

(Cottraux, 2014) which cause high dropout rates (up

effectiveness between CBT and VRET in treating

to 48%) (McDonagh et al., 2005).

patients with PTSD, recommendations for how to incorporate VR into psychiatric care, and future

184

directions for VR based treatment and clinical

independently evaluate the risk of bias. Then,

research (McLay et al., 2011).

categorize the risk of bias as a whole. 2.4. Data extraction

Method This systematic review is based on Preferred

Data from each journal is collected and then

Reporting Items for Systematic Review and Meta-

inputted into a table. The data taken: 1) characteristics

Analysis statement (PRISMA) and was organized

of participants (sample size, age of participants and

adhering to previously recommended guidelines for

diagnostic information); 2) intervention features

transparent

(study length, details of the control group and any

and

comprehensive

reporting

additional

methodology and result.

intervention

components);

post-

treatment using CAPS for PTSD treatment. If there is

2.1. Search strategy This study uses an electronic search tool with

incomplete data, the researcher contacted his authors

databases: PubMed, MEDLINE, PsyIndex, US

by e-mail to retrieve the data, and if they did not

Clinical Trials starting from 31 August 2019. To

provide a response then the studies were excluded.

further add references, this study also retrieves data

2.5. Statistical analysis All analysis were conducted by Review

using reference lists with relevant types of studies.

Manager 5.3. The researcher carried out a meta-

2.2. Eligibility criteria Eligibility studies were randomized controlled

analysis by including the mean CAPS Post-treatment

trials (RCTs) and randomized uncontrolled trials

of several domains that met the criteria for

(RUTs) included participants with the primary

quantitative analysis. Meanwhile, heterogeneity

diagnosis of PTSD, looking at interventions used

testing was conducted between studies. I2> 50%,

namely virtual reality with results to assess PTSD

pâ&#x2030;¤0.05, showed significant heterogeneity, and the

based on CAPS. The control group received at least

random effect model was used. If not, a fixed effect

one non-VRET group including CBT, PE, TAU, or

model is performed.

others. There is no limit to the causes of PTSD

2.6. Publication bias and additional analysis

diagnoses such as postwar PTSD, PTSD street accidents, PTSD post terrorists, etc. Only English journals are taken and reviewed. The selection of inclusions in this research was carried out with two independent reviewers (T.A and A.A) screened the title and abstracts to identify eligible studies.

The presence of publication bias was evaluated by drawing a funnel plot. Additionally, for situations that the heterogeneity is too large, Duval and Tweedie's trim-and-fill analysis was conducted to recalculate the pooled effect size after removing any studies which may introduce publication bias (i.e.,

2.3. Quality assessment This study uses the Review Manager 5.3 application as a tool to assess the risk of bias in selection, performance, detection, attrition, and outcome reporting then grouping it into high, low or unclear for risk of bias. Two authors (T.A and A.A)

185

small studies with large effect sizes from the positive side of the funnel plot) (Duval & Tweedie, 2000), and â&#x20AC;&#x153;fail-safe Nâ&#x20AC;? was used to account for the file draw problem, estimating the number of negative results which would be required to invalidate the current meta-analysis.

Manual of Mental Disorders-Four Edition (DSM-IV)

3. Result A preliminary search obtained 103 articles and

(APA,2000) criteria for PTSD based on the Clinician-

three further articles were retrieved following an

Administered PTSD Scale (CAPS) (Blake et al.,

additional search. Seven duplicate articles were

1995). Among them, there are two prolonged

removed. The authors read the title and abstract of

exposure (PE), one treatment as usual (TAU), and a

remaining 92 articles for preliminary screening.

control exposure therapy(CET) (JoAnn, 2019;

Author excluded literatures with reason including

McLay et al., 2017, 2011; Reger et al., 2016).

animal experiment, case report, editor response,

3.2. Risk of bias assessment

protocol, review and related meta-analysis. Finally, full texts were retrieved for 7 papers and 4 studies include for qualitative and quantitative synthesis (JoAnn, 2019; McLay et al., 2017, 2011; Reger et al., 2016). The literature screening process is shown in Fig. 1.

Result from Review Manager 5.3 for risk of bias assessment are displayed in Fig.2A. As stated in Fig. 2B, the frequent risk factor for bias was

was

incomplete outcome data (attrition bias), with only 1 of 4 studies yang memiliki low risk of attrition bias. It is due to the included trial studies in this systematic

3.1. Characteristic of included studies Full details of each study are displayed in Table 1. Outcome data were avaliable from 4 studies including three RCTs and one RUT. All papers

review took a rather long period of time (3 to 6 months) with tiered and continuos follow-up system. 3.3. Between-group effect of VRET and CBT on PTSD

reported outcome data in a format suited for meta-

We compared the pooled effect size of VRET on

analysis. Mean sample ages ranged from 18 to 65

PTSD to control conditions in a fix-effects model.

years. Patients in these studies were veterans and

Moderate pooled effect size was observed (4 studies,

active duty military personnel with combat-related

n=339, z=1.26, 95% CI: -2.08â&#x20AC;&#x201C;9.60, p=0.21) (see Fig.

PTSD (JoAnn, 2019; McLay et al., 2017, 2011; Reger

3 for the forest plot). The result shows that Cognitive

et al., 2016) that met Diagnostic and Statistical

Behavior Therapy (CBT) tends to be more effective

186

compared to Virtual Reality Exposure Therapy

model. The funnel plot is presented in Fig. 4 and

(VRET) although with a low significance (p=0.21).

Duval and Tweedie's trim-and-fill analysis identified

There was moderate heterogeneity across the study

no outlier studies.

data (p=0.17, I =40%), so we chose a fix-effects Record identified through database searching (n=103) PubMed MEDLINE PsyIndex U.S Clinical Trial

Additional records identified through other database (n=3)

Duplicates Removed (n=7) Records excluded with reason (n=92) - 31 other design study - 31 other compare - 30 other outcome

Record Screened (n=99)

Full-text articles assessed for eligibility (n=7)

Full-text articles exclude with reason (n=3) - 3 not enough data reported

Studies included in qualitative syntehsis (n=4)

Studies included in quantitative syntehsis (n=4) Fig. 1. PRISMA flow chart of study selection structure so that it can be modified. CBT utilizes the

4. Discussion The treatment protocol in this study compared

techniques of imaginal exposure to accomplish this

manualized CBT to the use of VRET as a replacement

but concerns about the potential for patient under

for imaginal exposure. Regarding to the treatment

engagement to deal with clinical outcomes for some

stigma, our hypothesis that PTSD patient assigned to

patients have been noted (â&#x20AC;&#x153;The expert consensus

VRET would demonstrate significant reduction in

guideline series. Treatment of Post-traumatic Stress

treatment relative to receiving CBT.

Disorder. The Expert Consensus Panels for PTSD,â&#x20AC;?

VRET emerges from its presumed role in

1999). However, in the context of treatment, the

emotional processing theory (Foa et al., 2018).

effective use of VRET assumes that the virtual

Patients rewind traumatic events to activate the fear

environment is successful at facilitating activation of

187

the fear structure. Multisensory virtual reality systems with customizable virtual environments have been conceptualized as a tool to increase emotional

Fig. 2. Quality assessment of RCTs. (A) Risk of bias summary: review authors’ judgements about each risk of bias item for each included study. (B) Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies.

engagement and we see the potential that VRET improves clinical outcomes.

virtual reality stimulator. We also found no evidence that virtual reality encouraged greater engagement in

Contrary to expectations, we did not observe any

treatment. This ﬁnding is consistent with previous

signiﬁcant difference in PTSD outcomes when

trials that many forms of therapy for PTSD, have

comparing the results of exposure therapy with 188

found no advantage of VRET over traditional

choice increased rate of psychotherapy utilization

prolonged exposure therapy (CBT).

among PTSD patient. This question will have to be

We presume that the reason why the effectiveness

answered in future research.

of VRET is not as expected compared to CBT as

This does not mean that any individual with PTSD

treatment is due to the main target of CBT is to treat

should abandon hope. Although not all treatments

patient’s cognitive behavior itself, that has the most

work for PTSD, several comparative studies now

effect on PTSD patients and has to be corrected, with

indicate that at least a number of therapy options can

the

offer a reasonable chance at success. Finally, virtual

psychiatrist and the patient that affects mental

reality and other technologies continue to improve,

improvement progressively. Moreover, we concern

and as more options are offered, any given individual

that VRET could trigger patients’ trauma and become

with PTSD is more likely to ﬁnd a treatment that

a contraindication for PTSD patients. However, the

helps their condition. Also, it will be the key to

interpersonal

communication

with

present study did not address the important question of whether the availability of VRE as a treatment

Fig. 3. Meta-analysis of the effect of VRET on PTSD in comparison of control. Box size represents study weighting. Diamond represents overall effect size and 95% CI.

Fig. 4. Funnel plot of VRET vs. no VRET.

189

investigate characteristics that may lead patients to

Anxiety Disorders, 61, 64–74.

their best treatment option.

https://doi.org/10.1016/j.janxdis.2017.08.00

Conclusion

VRET is not significantly effective as a treatment for PTSD compared to CBT. Although it is not better

Kaloupek, D. G., Gusman, F. D., Charney,

than conventional therapies, VRET is worth to be

D. S., & Keane, T. M. (1995). The

combined with CBT. The main target of CBT is to

development of a Clinician-Administered

correct patient’s cognitive behavior.

PTSD Scale. Journal of Traumatic Stress, 8(1), 75–90.

6. Recommendation To incorporate VRET into psychiatric care and future directions for VRET based treatment and

Cottraux. (2014). Virtual Reality Exposure Therapy for Adults with Post-Traumatic Stress Disorder: A Review of the Clinical

clinical research. 7.

Blake, D. D., Weathers, F. W., Nagy, L. M.,

Effectiveness. Retrieved from

References

http://www.ncbi.nlm.nih.gov/books/NBK25

Arnberg, F. K., Bergh Johannesson, K., & Michel,

3832/ Duval, S., & Tweedie, R. (2000). Trim and fill: A

P.-O. (2013). Prevalence and duration of PTSD in survivors 6 years after a natural

simple funnel-plot-based method of testing

disaster. Journal of Anxiety Disorders,

and adjusting for publication bias in meta-

27(3), 347–352.

analysis. Biometrics, 56(2), 455–463. Fitch, T., Villanueva, G., Quadir, M. M., Sagiraju,

https://doi.org/10.1016/j.janxdis.2013.03.01

H. K. R., & Alamgir, H. (2015). The

prevalence and risk factors of Post-

Barredo, J., Aiken, E., van ’t Wout-Frank, M., Greenberg, B. D., Carpenter, L. L., & Philip,

Traumatic Stress Disorder among workers

N. S. (2019). Neuroimaging Correlates of

injured in Rana Plaza building collapse in

Suicidality in Decision-Making Circuits in

Bangladesh. American Journal of Industrial

Post-traumatic Stress Disorder. Frontiers in

Medicine, 58(7), 756–763.

Psychiatry, 10, 44.

https://doi.org/10.1002/ajim.22471 Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D.,

https://doi.org/10.3389/fpsyt.2019.00044

Yadin, E., Yarvis, J. S., … STRONG STAR

Baus, O., & Bouchard, S. (2014). Moving from Virtual Reality Exposure-Based Therapy to

Consortium. (2018). Effect of Prolonged

Augmented Reality Exposure-Based

Exposure Therapy Delivered Over 2 Weeks

Therapy: A Review. Frontiers in Human

vs 8 Weeks vs Present-Centered Therapy on

Neuroscience, 8.

PTSD Symptom Severity in Military

https://doi.org/10.3389/fnhum.2014.00112

Personnel: A Randomized Clinical Trial. JAMA, 319(4), 354–364.

Beidel, D. C., Frueh, B. C., Neer, S. M., Bowers, C.

https://doi.org/10.1001/jama.2017.21242

A., Trachik, B., Uhde, T. W., & Grubaugh,

Gerardi, M., Cukor, J., Difede, J., Rizzo, A., &

A. (2019). Trauma management therapy with virtual-reality augmented exposure

Rothbaum, B. O. (2010). Virtual reality

therapy for combat-related PTSD: A

exposure therapy for post-traumatic stress

randomized controlled trial. Journal of

disorder and other anxiety disorders.

190

Current Psychiatry Reports, 12(4), 298–305.

Cyberpsychology, Behavior, and Social

https://doi.org/10.1007/s11920-010-0128-4

Networking, 14(4), 223–229. https://doi.org/10.1089/cyber.2011.0003

Gerardi, M., Rothbaum, B. O., Ressler, K., Heekin,

Reger, G. M., Koenen-Woods, P., Zetocha, K.,

M., & Rizzo, A. (2008). Virtual reality exposure therapy using a virtual Iraq: Case

Smolenski, D. J., Holloway, K. M.,

report. Journal of Traumatic Stress, 21(2),

Rothbaum, B. O., … Gahm, G. A. (2016).

209–213. https://doi.org/10.1002/jts.20331

Randomized controlled trial of prolonged

JoAnn. (2019, July 2). Enhancing Exposure Therapy

exposure using imaginal exposure vs.

for Post Traumatic Stress Disorder (PTSD):

Virtual reality exposure in active duty

Virtual Reality and Imaginal Exposure With

soldiers with deployment-related Post-

a Cognitive Enhancer - Tabular View -

traumatic stress disorder (PTSD). Journal of

ClinicalTrials.gov. Retrieved October 1,

Consulting and Clinical Psychology, 84(11),

2019, from

946–959.

https://clinicaltrials.gov/ct2/show/record/NC

https://doi.org/10.1037/ccp0000134 The expert consensus guideline series. Treatment of Post-

T01352637 McDonagh, A., Friedman, M., McHugo, G., Ford, J.,

traumatic Stress Disorder. The Expert Consensus

Sengupta, A., Mueser, K., … Descamps, M.

Panels for PTSD. (1999). The Journal of Clinical

(2005). Randomized Trial of Cognitive-

Psychiatry, 60 Suppl 16, 3–76.

Behavioral Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of Childhood Sexual Abuse. Journal of Consulting and Clinical Psychology, 73(3), 515–524. https://doi.org/10.1037/0022-006X.73.3.515 McLay, R. N., Baird, A., Webb-Murphy, J., Deal, W., Tran, L., Anson, H., … Johnston, S. (2017). A Randomized, Head-to-Head Study of Virtual Reality Exposure Therapy for Post-traumatic Stress Disorder. Cyberpsychology, Behavior and Social Networking, 20(4), 218–224. https://doi.org/10.1089/cyber.2016.0554 McLay, R. N., Wood, D. P., Webb-Murphy, J. A., Spira, J. L., Wiederhold, M. D., Pyne, J. M., & Wiederhold, B. K. (2011). A Randomized, Controlled Trial of Virtual Reality-Graded Exposure Therapy for PostTraumatic Stress Disorder in Active Duty Service Members with Combat-Related Post-Traumatic Stress Disorder.

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AMINO | PCC EAMSC 2020: INDIA

Fibrin Sealant as A Topical Hemostatic Agent for Reducing Postoperative Blood Loss in Orthopedic Surgical Setting: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Aruni Cahya Irfannadhira*, Ekida Rehan Firmansyah, Ugiadam Farhan Firmansyah, Yehezkiel Alexander Eduard George *aruni.cahya@ui.ac.id Asian Medical Studentsâ&#x20AC;&#x2122; Association-Indonesia Introduction: In Indonesia, twelve from the 100,000 population have a fatal effect due to traffic accident. The most common case in a traffic accident is bone trauma which needs orthopedic surgery immediately. Bleeding is a major complication of surgery and increase the mortality rates to 20 percent if the severe bleeding occurs during or post-surgery. Fibrin sealant is novel innovation in bleeding management which currently developed since the twentieth century. Objectives: Our systematic review and meta-analysis is conducted (1) To evaluate the use of fibrin sealant as a hemostatic agent in reducing postoperative bleeding; (2) To recommend the future application of fibrin sealant in orthopedic surgical setting. Methods: Our study consists of randomized controlled trial from PubMed, ScienceDirect, Scopus, and EBSCOHost and found 843 journals. We found eight full-text articles which meets inclusion and exclusion criteria. We only include 5 articles for quantitative analysis. For further review, those literatures were assessed their risk of bias using the Cochrane Collaboration Tools. Results and Discussion: This systematic review and meta-analysis discusses about some types of fibrin sealant that are being used in orthopedic surgery. Those are BSTC fibrin glue, Tissucol/Tisseel fibrin glue, Quixil, and Evicel. From this study, we found that fibrin sealant has no significant result in reducing blood loss in orthopedic surgical setting (p=0.53). A new hemostatic agent, Traumagel has a promising function to reduce blood loss in animal experiment. Further studies have to be conducted to observe its efficacy and side effects on humans. Conclusion: Our study did not find significant difference between fibrin sealant application and control group on postoperative blood loss. Also, fibrin sealant has relatively expensive cost. Hence, we do not recommend future application of fibrin sealant to reduce blood loss in orthopedic surgical setting. Keyword: Blood loss, fibrin sealant, hemostatic agent, orthopedic surgery, traumagel

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ABSTRACT Obstetric Emergency Training Approaches to Reduce Maternal Mortality Ratio in Indonesia: A Systematic Review 1

Yessica Chelsea Horax , Vanessa Carolina Gunawan2, Kartika Palmasari1, Yolandita Chrisan Berliana1 1

2nd year medical student, 23rd year medical student University of Brawijaya AMSA-INDONESIA

Introduction Maternal mortality ratio (MMR) remains a priority under Goal 3: Ensure healthy lives and promote well-being for all at all ages in SDGs. Indonesia still needs a lot of effort reduce MMR since in 2015 there is still 305 per 100.000 live births. Several studies have indicated the main factors associated with high maternal mortality are low quality of skilled birth attendance care, lack of access to functioning comprehensive, basic emergency and obstetric facilities. Obstetric emergency training could be the way to resolve and also brings a greater impact on this issue by improving the quality of health worker on obstetric skill levels. Material and method We searched the following database or websites without language restriction in 10 years period with keyword “Obstetric Emergency Training”: -

Cochrane Central Register of Controlled Trials

PubMed

Science Direct

Result and Discussion We included nine studies after found 18 potentially studies. Then we exclude the other 9 because they did not meet the study design inclusion criteria. In our study, there are many kinds of obstetric emergency training methods such as simulation, checklist, smartphone training tool, ACLS and obstetric emergencies training, blended curriculum approach, mobile simulation workshop. One of the training that meet our criteria is PRONTO, a simulation-based program that provides training for interprofessional healthcare teams using highly-realistic and low-cost simulation. The researcher found significant effects on the outcome variables at four, eight, and twelve months after the intervention. This method is efficient and low-cost, so it can be applied in Indonesia’s rural areas. This method also has a complex but applicable curriculum that covers most of the obstetric problem.

197

Conclusion Among them, we found the best method that can be implied in Indonesia which is “PRONTO” from Fritz’s study. Keyword : obstetric, maternal mortality, emergency training

198

199

ABSTRACT A New Era: The Use of Technology to Assist Triage in Mass Casualty Incident (MCI) Settings: A Systematic Review Shafa Maulida, Nanda Ayu Sabrina, Wiranigitasari, Serri Rivally Asian Medical Students’ Association Indonesia

Aim •

To assess the effects of technology assisted triage in improving the management of mass casualty incidents (MCI)

Background MCI are disasters and major incidents that can rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care. MCI triage systems are implemented to offer the greatest good to the greatest amount of people as healthcare resources are limited or strained due to the number of injured individuals. New technologies have the potential to play an important role in improving many aspects in emergency and disaster response to MCI. However, the scientific evidence of these interventions is still lacking. Brief Research Methodology We identified trials through systematic searches of the following bibliographic databases; CENTRAL, PubMed, Science Direct, and Google Scholar on 14th to 21st September 2019. The search terms were: “technology” OR “triage” OR “management” OR “mass casualty incident”. We intended to review randomised controlled trials (RCTs) and nonrandomised trials with assessment of outcomes that evaluated the technology-assisted triage in the management of MCI. Key Findings Three RCTs and eight quasi experiments are included in this review. There are variable and novel technology-based interventions that could improve the triage process in MCI. The interventions discussed are RFID tags, smart glasses, and mobile phone equipped with wireless connection such as NFC. These interventions could enhance the quality of triage in several aspects such as improving patient tracking, triage accuracy, information management and dissemination, and decision support system for responders.

200

Conclusion The use of novel technology for improving the effectiveness and quality of triage in MCI based on the several included studies with various types of intervention shows many beneficial results. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies.

Keyword: mass casualty incident management; triage; technology

201

A New Era: The Use of Technology to Assist Triage in Mass Casualty Incident (MCI) Settings (A Systematic Review) Shafa Maulida1, Nanda Ayu Sabrina1, Wiranigitasari1, Serri Rivally1 1 AMSA-Indonesia

BACKGROUND

RESULT AND DISCUSSION

1. The World Health Organization defines mass casualty incidents as disasters and major incidents that can rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care. 2. Between 1984 and 2013, Indonesia experienced 325 natural disasters, accounting for 190,794 deaths and costing approximately US $26 billion in damage (EM-DAT, 2013). 3. Mass casualty incident triage systems are implemented to offer the greatest good to the greatest amount of people as healthcare resources are limited or strained due to the number of injured individuals. 4. The triage process has become an important element of emergency care service since it is a continuous process which ensures that patients obtain a level of care appropriate to their clinical need and in a timely manner (FitzGerald et al, 2010) 5. The implementation of informatics solutions and information technology (IT) could have significant beneficial impact, but like IT in healthcare in general, adoption has been slow for variety reasons, and faces a number of significant challenges.

OBJECTIVES OBJECTIVES Assess the effects of technology assisted triage in improving the management quality of mass casualty incidents

Table 1. Characteristics of Studies No.

Author,year

Study Design

Population

Intervention

Control

Outcomes

Jokela, et al. 2012

Quasi experimental

Finland: 45 stimulated ship passengers Sweden: 20 simulated airplane passengers

Using RFID technology: Technology to communicate through radio waves.

Paper-based triage documentation

Usability: System was quick, stable, and easy to use, and proved to work seamlessly Efficacy: All information about the casualties was available one hour earlier than the traditional method using paper tags.

Boltin, et al. 2018

quasiexperimental

13 nurses and 296 patients

EDICT software; Fast and accurate data collection through aggregation and dissemination of information; re-engineering of the patient processing protocol

Usability: 97.3% were able to complete the kiosk system either on their own or with an assistant. Efficacy: The data showed strong agreement among nurses.

Lenert, et al. 2011

Randomized controlled trial

100 simulated victims (50 paper based, 50 electronic WIISARD pathway)

WIISARD program: wireless scalable rapidly deployable electronic medical records (EMRs) for victim tracking and field care at disaster sites.

Paper-based

The WIISARD improve the quality and dissemination of collected information.

Broach, et al. 2018

Ingrassia, et al. 2012

Rodriguez, et

al 2014

15 paramedics

Smart glasses (e.g. head-mounted computers that can project first person, point-of-view data to a remote viewer)

It remote physician triage achieve the same level of inter-rater reliability as in person physician triage and suggest that using such a platform to begin secondary triage remotely, prior to patient arrival in the ED, would have a similar reliability compared to in person secondary triage upon patient arrival.

Quasi experimental

Fifty-three volunteers

demonstrate the applicability and the reliability of a radio frequency identification (RFID) system to collect data during a live exercise

Traditional paper recording system

The system proved to be a valid and easy system allowing fast data collection, automated analysis, and immediate data availability for debriefing.

quasiexperimental

total 300 first responders (paramedics) in eleven emergency drills: 25 actors for each drills

wrist wearable device with wireless communication functions

manual triage

The sensor-based triage achieved 53.5% accuracy for all patient.

31 paramedics and 12 patients

A specific Android app was designed for use with Smart Glasses, which added information in terms of augmented reality with two different methods—through the display of a triage algorithm in data glasses and a telemedical connection to a senior emergency physician realized by the integrated camera.

Conventional triage

The triage group wearing data glasses and being telemedically connected achieved 90% accuracy (P=.01) in 35.0 seconds.

conventional, paper-based methods

Medical documentation of victim START components and triage acuity were better for WIISARD compared to controls (overall acuity was documented for 100% vs 89.5%, respectively, difference = 10.5% [95%CI = 0.5–24.1%]).

Paper based evacuation

the DIORAMA system can significantly reduce the evacuation time (up to 43%)

Traditional paperwork triage

There was significant difference in the total triage time and the accuracy between the NFC group and the paperwork group.

Quasi experimental

Follmann, A, et Randomized al.2019 controlled trial

METHODS 8.

We identified trials through systematic searches of the following bibliographic databases; CENTRAL, PubMed, Science Direct, and Google Scholar on 14th to 21st September 2019. The search terms were: “technology” OR “triage” OR “management” OR “mass casualty incident”.

9. 10

11.

Excluded

Chan, et al. 2010

Randomizedcontrolled trial

100 simulated disaster victim

wireless, electronic, field, medical record system prototype (“Wireless Internet Information System for medical Response to Disasters” or WIISARD)

Ganz, et al. 2011

Quasi experimental

20 patients and 40 patients

‘DIORAMA’ system assist the incident commander in the management of a mass casualty incident

50 victims

DIORAMA-II system that provides real time information collection in mass casualty incidents

Cheng, et al. 2017

Quasiexperimental

50 EMT trainees

NFC-embedded smartphones for triaging

Systematic Review Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0

Total Samples:

- 1145 participants

Decision support system through clinical recommendation by the system

• Observational studies •Inaccessible full-text article •Studies published before 2009

- Cochrane Collaboration’s Tool for Assessing Risk of Bias

3 RCTs and 8 non-RCTs Qualitative Analysis

Figure 1. Conceptual Framework

Jokela, et al. 2012 Cheng, et al. 2017

Eligibility Criteria

Quality Assesment:

Boltin, et al. 2018

• Randomized Controlled Trials (RCT & non-RCTs (Quasi Experimental) • Last 10 years studies

Included

Figure 3. Cochrane Risk of Bias Assesment Summary

Patient Tracking for Mass Casualty Incident

Cone, et al. 2018 Ingrassia, et al. 2012

Summary of Main Result Six trials showed beneficial outcomes of technology in improving patientsʼ information management and dissemination through integrated real time data collection (Jokela, et al. 2012; Boltin, et al. 2018; Lenert, et al. 2011; Ingrassia, et al.2012; Chan, et al. 2010; Ganz, et al.2011; Cheng, et al. 2017). Three studies (Jokela, et al. 2012; Ganz, et al. 2011; Ingrassia, et al. 2012) incorporated radio frequency identification (RFID) devices which transmit information from casualty ID tags to reader devices through radio waves. One study evaluated the use of mobile application. Two randomized controlled trials (Lenert, et al. 2011; Chan, et al. 2010 ) showed that Wireless Internet Information System WIISARD) has appeared to improve the quality of information collected, medical documentation and triage acuity, and enhance the dissemination of information across the response team Four trials has discussed the utilization of novel technology to improve triage accuracy in mass casualty incidents, (Rodriguez, et al. 2014; Broach, et al. 2018; Follmann, et al. 2019; Cheng, et al. 2017). A study by Follmann showed that the use of Smart Glasses to display triage algorithm resulted in better triage accuracy than conventional methods. In 2017, Cheng et al studied the effects of Near Field Communications (NFC) embedded smartphones and they found significant benefits in reducing total triage time and improving the triage accuracy compared with the paperwork group.

Follman, et al. 2019

Improving patientsʼ information management and dissemination through integrated

Rodriguez, et al. 2012

Improving Triage Accuracy in Mass Casualty Incident

Ganz, et al. 2017 Ganz, et al. 2011 Chan, et al. 2010 Lenert, et al. 2011

Electronic Triage Accuracy in Mass Casualty Incident

Figure 4. Group Based on Interventions Applicability of Evidence The results of our systematic reviews has confirmed the successful use and implementation of technology based triage that is feasible during mass casualty incident situations. Although the paper-based conventional triage method is relatively inexpensive alternative, there are several problems (such as easy to lost, get destroyed, limitation at data accuracy, ambiguous identification numbers, duplicate identification numbers, combinations of ambiguously labeled and doubly labeled identifiers) (Lanert L, 2011 & Jokela J, 2012). Even though this replacement of traditional paper-based record base or triage in disaster care with an electronic one may have complex design and geolocation technologies challenge and require further development, this system is proved to be easy to use and appeared to be a practical technology (Lenert L, 2011). Beside of improving quality of triaging in mass casualty incident, technology-based triage could also have important secondary benefits such as being a repository for collecting patient data (Follmann A, 2019 & Ganz A, 2011).

Limitations

Figure 2. PRISMA flow chart of search strategies

REFERENCES Boltin, N., Valdes, D., Culley, J. M., & Valafar, H. (2018). Mobile decision support tool for emergency departments and mass casualty incidents (EDIT): initial study. JMIR mHealth and uHealth, 6(6), e10727. Broach, J., Hart, A., Griswold, M., Lai, J., Boyer, E. W., Skolnik, A. B., & Chai, P. R. (2018, January). Usability and reliability of smart glasses for secondary triage during mass casualty incidents. In Proceedings of the... Annual Hawaii International Conference on System Sciences. Annual Hawaii International Conference on System Sciences (Vol. 2018, p. 1416). NIH Public Access. Chan, T. C., Griswold, W. G., Buono, C., Kirsh, D., Lyon, J., Killeen, J. P., ... & Lenert, L. (2011). Impact of wireless electronic medical record system on the quality of patient documentation by emergency field responders during a disaster mass-casualty exercise. Prehospital and disaster medicine, 26(4), 268-275. Cheng, P. L., Su, Y. C., Hou, C. H., & Chang, P. L. (2017). Management of In-Field Patient Tracking and Triage by Using Near-Field Communication in Mass Casualty Incidents. In MedInfo (p. 1214). Guha-Sapir, D., Below, R., & Hoyois, P. EM-DAT: The OFDA/CRED International Disaster Database. Université Catholique de Louvain, Brussels, Belgium, 2013. Follmann, A., Ohligs, M., Hochhausen, N., Beckers, S. K., Rossaint, R., & Czaplik, M. (2019). Technical support by Smart Glasses during a mass casualty incident: A randomized controlled simulation trial on technically assisted triage and telemedical app use in disaster medicine. Journal of medical internet research, 21(1), e11939. Ganz, A., Yu, X., Schafer, J., & Lord, G. (2011, November). Real-time scalable resource tracking framework (DIORAMA): System description and experimentation. In 2011 IEEE International Conference on Technologies for Homeland Security (HST) (pp. 407-412). IEEE. Ganz, A., Schafer, J., Yu, X., Lord, G., Burstein, J., & Ciottone, G. R. (2013). Real-time scalable resource tracking framework (DIORAMA) for mass casualty incidents. International Journal of E-Health and Medical Communications (IJEHMC), 4(2), 34-49. Higgins, J. P., & Green, S. (Eds.). (2011). Cochrane handbook for systematic reviews of interventions (Vol. 4). John Wiley & Sons. Higgins, J. P., Altman, D. G., Gøtzsche, P. C., Jüni, P., Moher, D., Oxman, A. D., ... & Sterne, J. A. (2011). The Cochrane Collaborationʼs tool for assessing risk of bias in randomised trials. Bmj, 343, d5928. Ingrassia, P. L., Carenzo, L., Barra, F. L., Colombo, D., Ragazzoni, L., Tengattini, M., ... & Della Corte, F. (2012). Data collection in a live mass casualty incident simulation: automated RFID technology versus manually recorded system. European journal of emergency medicine, 19(1), 35-39. Jokela, J., Rådestad, M., Gryth, D., Nilsson, H., Rüter, A., Svensson, L., . . . Castrén, M. (2012). Increased situation awareness in major incidents--radio frequency identification (RFID) technique: A promising tool. Prehospital and Disaster Medicine, 27(1), 81-7. doi:http://dx.doi.org/10.1017/S1049023X12000295 Lenert, L. A., Kirsh, D., Griswold, W. G., Buono, C., Lyon, J., Rao, R., & Chan, T. C. (2011). Design and evaluation of a wireless electronic health records system for field care in mass casualty settings. Journal of the American Medical Informatics Association, 18(6), 842-852. Rodriguez, D., Heuer, S., Guerra, A., Stork, W., Weber, B., & Eichler, M. (2014, November). Towards automatic sensor-based triage for individual remote monitoring during mass casualty incidents. In 2014 IEEE international conference on bioinformatics and biomedicine (BIBM) (pp. 544-551). IEEE.

This review has several limitations, mainly caused by the limited availability of RCT study types that evaluated the use of novel technology for triage in mass casualty incidents. This availability of RCT limitation is due to the initiation of the development of electronic triage has just started in less than a decade. This availability limitation also affects the consistency of the model and tool that are compared in this study. Moreover, previous conducted studies related to the effectiveness of a tool or system in mass casualty incidents mostly were designed in a simulation and/or trial situation that definitely has a different condition compared to the real-situation. There are some unpredictable circumstances in real-situation that might inhibit the applicability of electronic triage, such as lack of connection, electrical energy, and any other situation.

CONCLUSION AND RECOMMENDATIONS The use of novel technology for improving the effectiveness and quality of triage in mass casualty incidents based on the several included studies with various types of intervention shows many beneficial results. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies. We sincerely hope that this review can be used as a suggestion for the government, and any party that takes part in managing mass casualty incidents to consider switching the use of paper based triage to technology-assisted triage in the future, because the utilization of the interventions such as those included in this review could alleviate the problem of limited human resources in mass casualty incidents, by making their work more efficient. All types of technology-based triage that has been discussed in this review do need further assessment and development before it can be used widely in mass casualty incidents.

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Potency an Inactivation of PCSK9 Gene to Decrease LDL-C Level Through Genetic Engineering CRISPR / CAS9 as Innovative Efforts to Prevent Coronary Heart Disease: A Systematic Review Faqrizal Ria Qhabibi1, Vanessa Carolina Gunawan2, Shafa Maulida3, Rendy Wijaya4 1. 3rd Years Medical Student, Brawijaya University 2. 3rd Years Medical Student, Brawijaya University 3. 2nd Years Medical Student, Brawijaya University 4. 2nd Years Medical Student, Brawijaya University

ABSTRACT Background: Coronary artery disease (CAD) is one of the life-threatening metabolic diseases that affect the cardiovascular system. CAD caused by many risk factors, one of the most prevalence is the deposition of low-density lipoprotein (LDL) inside blood vessels. Novel studies show the genetic aspect is important in the pathogenesis of Coronary Heart Disease, one of them is the Pcsk9 gene that controls LDL-C level inside the blood. By the advancement in technology, the use of genetic engineering with CRISPR/Cas9 becomes a novel strategy to overcome and prevent health problems. Aim: To find the best method which can decrease the degradation rate of LDL receptor protein (LDL-R) to decrease the level of LDL-C on plasma. Method: Reviewed papers were obtained using databases or websites without language restriction in 10 years period from 2008-2018 with keyword “Coronary Heart Disease” AND “LDL Cholesterol” AND “CRISPR/Cas9” AND “Pcsk9. Also using search engines such as Proquest (2009 to present), PubMed (2008 to present), and Science Direct (2008 to present). Assessment of risk of bias in experimental studies using the Cochrane risk-of-bias tool. Result and Discussion: Is founded 22 potentially relevant papers on that examine LDL-C and total cholesterol level on serum. Then excluded 18 articles because they did not meet the study design inclusion criteria. Based on qualify papers reveals that inactivation of the Pcsk9 gene is effective in reducing LDL-C levels in blood plasma due to the rate of degradation of LDL-R protein decreases

that

with

increase

the

amount

LDL-R

protein

cell

membranes. Conclusion: Inactivation of the Pcsk9 gene using genetic engineering CRISPR/Cas9 is expected to be a solution in overcoming the high prevalence of CHD. Keywords: Coronary Heart Disease (CHD), CRISPR/Cas9, LDL Cholesterol (LDL-C), Pcsk9 Gene

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Application of Intravenous Artesunate for Severe Imported Malaria Based on WHO Guideline: A Review Febby G. Siswanto1, Ellen J. Handoko1, Maria S. Cahyaningrum1, Farida Aisyah1 1

Second Year of Medical Student, University of Sebelas Maret Surakarta [corresponding email: febbygunawans@gmail.com] Abstract

Aim The aim of this research is to review and understand the application of Intravenous Artesunate (IVA) for treating severe imported malaria using the World Health Organization (WHO) guideline. Introduction Severe malaria is considered a medical emergency which makes aggressive antimalarials and intensive clinical management a must. Early stage of malaria have no evidence of organ dysfunction. Full recovery is expected but if the treatment is delayed or the antimalarial is ineffective, P. falciparum can cause lethal severe malaria within a few hours. Methodology This review was conducted with PRISMA guidelines. Database used in this review is PubMed, performed with keyword (((((((severe) OR complicated) NOT uncomplicated)) AND malaria) AND (((management) OR therapy) OR intervention)) AND cohort) NOT review. Criteria of inclusion were English only articles, published in the last 5 years, and discuss malaria management. After screening of articles related to keyword, 2 articles were obtained to conduct this review. Discussion and Result 1544 cases show patients with severe malaria who received IVA had 2.9% mortality rate, while patients who received quinine had 3.9% mortality rate. Another study shows 4 patients experienced IVA intervention and rapidly improved from parasitaemia. All were discharged from hospital with no complications. It was also

1 205

proven that IVA combined with RBC exchange resulted in patients' survival with no long term renal or neurological sequale. Conclusion Intravenous artesunate with/without erythrocyte exchange is an effective first line treatment for severe imported malaria Key Finding Intravenous Artesunate, Severe Malaria, Quinine, RBC Exchange, IVA

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ABSTRACT

TELEMEDICINE AS A BREAKTHROUGH IN PRE-HOSPITAL MANAGEMENT OF ACUTE CORONARY SYNDROME (ACS) : A SYSTEMATIC REVIEW Ni Made Susanti1, Luh Elda Geraldine1, William Wiradinata1, Putu Ijiya Danta1 1

Medical Faculty of Brawijaya University

Introduction : Acute coronary syndrome is the number one leading cause of death in the world. Telemedicine, accompanied with technological improvements, could help in increasing the efficiency of ACS management, especially in rural areas, or for people with low to middle income. Understanding the advantages and problems that may occur in the implementation of telemedicine became a crucial point before implementing the new found ideas and technologies into the field. Objective : To review the success in different countries and different settings, identify the principle characteristics, and analyze the further utilization of the Pre Hospital Telemedicine in Management of Acute Coronary Syndrome for Indonesian healthcare. Materials and Methods This systematic review was conducted based on PRISMA guidelines. Study characteristics were presented as PICO in Table 1. The methodological quality was assessed using the risk-of-bias assessment tool based on the Cochrane Handbook for Systematic Reviews of Interventions ( v 5.1.0). Study selection and data collection were performed independently in an unblinded standardized manner by 4 reviewers Results Four studies were included in the systematic review. In 4 studies, selection bias and measurement of exposure were adequately generated. Blinding of the outcome and cofounding variables of bias weren't clearly addressed. But all studies had good quality in reporting bias.

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Discussion Telemedcine allows the early diagnosis of ACS, reduces the delay to definitive treatment either in reperfusion, chemical, or mechanical therapy, effective in reducing time to diagnosis in several area such as peripheral mountain areas, and improving initial care response by aspirin on first contact. Conclusion Telemedicine is a promising frontier that can be used to solve this nation's health inequality and health coverage. The tele-ECG allows the early diagnosis of ACS, reducing the delay to definitive treatment, be it reperfusion, chemical, or mechanical therapy

Keywords : Acute Coronary Syndrome (ACS), Pre-hospital, Telemedicines

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KNOWLEDGE ON HYPOGLYCEMIA AMONG PATIENTS WITH DIABETES MELLITUS Marito Lenny Tin Sianipar, Gloria Jessica Wekatano Wafom, Sherlye Maclaine Gunawan Universitas Kristen Indonesia Abstract Objective The objective of the study is to assess the level of knowledge of hypoglycemia among patients with diabetes mellitus in the rural community. Hypoglycemia is an acute complication of diabetes mellitus. The recognition of hypoglycemia and immediate treatment of hypoglycemia should be known by all the diabetic patients so that treatment of hypoglycemia may not be delayed, need for hospitalization could be avoided, and life-threatening complications due to hypoglycemia may be prevented. Introduction Hypoglycemia is an acute complication in diabetes mellitus, and it is the medical term for a state produced by a lower than normal level of blood glucose. Diabetes mellitus is a metabolic disorder characterized by more blood glucose level and disturbances in carbohydrates, fat, and protein metabolism and associated with a metabolic complication that can subsequently lead to premature death. The term hypoglycemia literally means " Under-sweet blood. It occurs when the blood glucose falls to < 40-50 mg/dl which may endanger a patient's life as well as another person's life. It can be caused by too much insulin intake or oral hypoglycemic agents, too little food or excessive physical activity. Methods A cross-sectional research design was adopted with 60 sample who met the inclusion criteria in the real community in India. The structured interview method was used the collect the data. Data were analyzed with descriptive and inferential statistics. Result Of 60 samples, 38(63.33%) had inadequate knowledge, 12 (20%) of them had moderately adequate had 10 (16.67%) of them had adequate knowledge. There is a significant association between the age and type of treatment at the level of p<0,05 with the level of knowledge on hypoglycemia.

Discussion

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Studies are congruent with the present study, and when compared with the present study findings, educational, the status of the client plays an important role in taking care of themselves and also people with diabetes mellitus have knowledge of self-care management, but still, they had very poor knowledge on hypoglycemia. Many of them had experienced the symptoms of hypoglycemia, but may not know what this is due to hypoglycemia caused by drug and improper diet, and they do not know the first aid measures to treat the hypoglycemia. Conclusion The study findings concluded that there is a lack of knowledge of hypoglycemia among patients with diabetes mellitus. Health care professionals have a major role in educating clients with diabetes mellitus about hypoglycemia risk factors, recognition of symptoms of hypoglycemia, first aid measures of hypoglycemia, blood glucose monitoring, and choice of proper regimens, thereby minimize the risk of hypoglycemia, and prevent the potential complications of hypoglycemia. Authors : Marito Lenny Tin Sianipar, Gloria Jessica Wekatano Wafom, Sherlye Maclaine Gunawan Faculty of Medicine, Universitas Kristen Indonesia maritosianipar@gmail.com (081382500895)

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AMINO | PCC EAMSC 2020: INDIA

AVOID COBRA & DO 3R: Snakebite Emergency Creative Campaign to Reduce Mortality and Morbidity due to Wrong First-Aid Treatment in the Community Dandy Bachtiar Hidayat1, Natasya Febrilia Yulianti2, Nabilla Yashinta Ixora3 1

Second Year Medical Student, Asian Medical Students’ Association Indonesia dandybachtiar18@gmail.com

Second Year Medical Student, Asian Medical Students’ Association Indonesia natasya.febrilla.yulianti@gmail.com

Second Year Medical Student, Asian Medical Students’ Association Indonesia nabillaysnt@gmail.com

Background: Snakebites are well known medical emergencies. It is a kind of serious neglected tropical health issue that causes death, disability, disfigurement, depravation, and destitution across continents. According to International Society on Toxicology (2014), India is the country with the biggest amount of snakebite envenoming cases occurring each year. Indonesia is ranked second with an average 113,881 cases each year. Indonesia is one of the most affected countries in South-East Asia Region, due to its high population density, widespread agriculture activities, presence of numerous venomous snakes, and the most important is lack of community awareness including wrong first-aid treatment of snakebite. Therefore, we make a public poster entitled AVOID COBRA & DO

3R as the abbreviation of the do’s and don’ts for snakebite emergency as creative campaign that is easy to remember. Objective: The aim is to reduce mortality and morbidity due to wrong snakebite emergency treatment in the community by socializing priority actions to achieve the vision of zero deaths from snakebite. Key Findings: snakebite, emergency, first-aid treatment. References World Health Organization, Regional Office for South-East Asia. (2016). Guidelines for the management of snakebites (2nd ed.). New Delhi, India. Ralph, R., Sharma, S. K., Faiz, M. A., Ribeiro, I., Rijal, S., Chappuis, F., & Kuch, U. (2019). The timing is right to end snakebite deaths in South Asia. BMJ (Clinical research ed.), 364, k5317. doi:10.1136/bmj.k5317

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ACUTE DIARRHOEA IN CHILDREN: SIMPLE BUT DEATHABLE AMSA-Universitas Jambi (M. Kholis Dzaky, Khiyaratul Husna, Denok Maretta Haq) Aim This poster is aimed to raise awareness and informed the right way to manage acute diarrhoea in children to parents in order to prevent diarrhoea as it may leads to death and disturbs children growth and development. Background/ Introduction Diarrhoea is the second leading cause of death in children under five years old. In low-income countries, children under three years old experience at about three episodes of diarrhoea every year. Diarrhoea is also a major cause of malnutrition and malnourished children is at high risk to fall ill from diarrhoea. Acute-onset diarrhoea is usually self-limited however, an acute infection can have a protracted course. Although acute diarrhoea is deathable and may increasing morbidity but it is actually preventable and treatable. Prevention aspect including community wide sanitation promotion, hand washing with soap, promoting exclusive six months breastfeeding, rotavirus vaccination, and good personal and food hygiene. While adequate treatment such as rehydration with low-osmolarity oral rehydration salt (ORS) solution, zinc supplementation, and continued feeding with nutrient-rich foods and breast milk. Brief Research Methodology This poster studies are based on report from UNICEF headquarter in the developing countries, with title â&#x20AC;&#x153;Diarrhoea: Why children are still dying and what can be doneâ&#x20AC;?. Key Findings Diarrhoea, Treatment, Prevention

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FIRST AID BURN INJURIES WITH “GET 4C” Muhammad Bariq Rifqi Pasha, Khoirunnisa Qurrota’ayun Nur Utami University of Pembangunan Nasional Veteran Jakarta, Indonesia Asian Medical Students’ Association Indonesia A burn is an injury to the skin or organic tissue caused by heat, radiation, chemicals, or others. WHO estimated 180.000 deaths every year caused by burns. In India, the prevalency of burn injury is around 6-7 million cases per year. Burn degree classification: first degree burns affecting superficial epidermis, second degree burns affecting epidermis and part of the dermis, third degree burns affecting the epidermis and the dermis, and fourth degree burns affecting all layers of the skin into muscle and bone, the tissue appear blackened. First aid for patient with burn wounds are: cool the burn with cool running water, clothes or jewelleries near the burnt area of skin should be removed, cover the burn by placing layer of cling film over, and call for help if the burn penetrates all layers of skin, leathery skin, charred looking, with white, brown, or black patches. Tips for burn prevention includes: checking home gas system, careful with candles and cigarettes, use sunscreen, and using handgloves in laboratory.

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TRAFFIC ACCIDENTS LIFE - SAVING

ABSTRACT Author : Astrid Cynthia Latief , Irgy Prijenka Ardhanariswara, Sagung Ngurah Anindita Pradnya Dewi Traffic accidents resulted 33,815 deaths in the Southeast Asian (Abbreviated Southeast Asia, Abbreviated SEAR) in 2010, with an average of 18.5 deaths per 100,000 populations. The average death due to traffic accidents is higher in middle-to-lower income countries with 19.5 deaths per 100,000 population than in poor countries with 12.7 traffic accident deaths per 100,000. populations. In Indonesia the average death from traffic accidents is 17,5 deaths per 100,00 populations based on global status survey on road safety 2013. This rate is keep increasing each year, because of the lack public public awareness of safety attitudes when driving, and not much people have well educated about what should they do to help the traffic accidents victim, and also one of them caused by help received by the victim is too late. Because of this basis we decided to take this topic into our poster project, in hope that this will also can increasing people awareness about traffic accidents life-saving. And, for the methodology we used in this Research is literature review. KEY FINDINGS : traffic accidents, traffic accidents life-saving, emergency medicine

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SEIZURE More Than 5 Minutes? Be SMART! Agnes Debora Sianturi, Ave Maria, Shantidewi AMSA-Universitas Brawijaya

Seizure is abnormal and excessive surge of electrical activity in the brain that causes abnormal movement. Many conditions cause seizures, one of which is infections/illness with fever in children. Seizure is a symptom, but untreated seizure will lead to neurons fatigue, if it continues progressively, it will impair the brain. That long-term complication will give meaningful developmental impacts to children. Besides preventing from short-term complications (difficulty in breathing, low O2 level, or social impacts), adequate first aid is highly required. This poster aims to socialize the first-aid treatments of seizure for parents or people close to children. This poster also aims to break the wrong belief that seizure is treated by administering spoon, coffee, or anything to the mouth, which is actually dangerous. This poster simplifies the first-aid treatments of seizure with the abbreviation of SMART: Stay calm; Make sure the breathing is fine, Lay the child on one side to prevent choking, Loosen clothing around neck, Leave nothing in the mouth to prevent breathing injury; Assess temperature and duration; Remember to stay close to the child during and after seizure; Take your child to hospital if seizure lasts 5 minutes, repeated, or when the temperature reaches 40OC or higher.

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FAST STEPS TO DETECT STROKE Faculty of Medicine Airlangga University Authors: Albertus Alarik, Samuel Davin, Quinamora Estevan

ABSTRACT Background From year to year, patients with stroke increases and stroke becomes one of the leading cause of death in Indonesia. Based on World Health Organization's data, stroke is the second leading cause of death in the world. Stroke is a disease that can attack anyone. Society rarely realize the stroke symptoms because it only happens for a short time. People usually ignore this kind of phenomenon whereas it is a sign that someone has attacked by stroke disease. By early detection and controlling risk factor, stroke can be prevented so it doesnâ&#x20AC;&#x2122;t cause disability and risk of death. Objective Our group made this poster to educate society about stroke symptoms so they can do early detection that prevent a further risk. Brief Research Methodology In the making process of this poster, we collected information and data from reliable sources as our content. This method known as literature review method. Key Findings Stroke, Stroke Symptoms, Health Education References : 1. World Health Organization, 2018, The Top 10 Causes Of Death, cited on Sunday, 29 September 2019 at 23.30 pm. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death 2. Hatzitolios, A.I., Spanou, M., Dambali, R., Vraka, K., Doumarapis, E., Petratos, K., Savopoulos, C. and Tziomalos, K., 2014. Public awareness of stroke symptoms and risk factors and response to acute stroke in N orthern G reece. International Journal of Stroke, 9(4), pp.E15-E15 3. Robinson TG, et al. Emerg Med J. 2013. Jun;30(6):467-71. doi: 10.1136/emermed-2012-201471. Epub 2012 Jul 4.

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F. A . S . T

Steps To Detect Stroke @#!&

FACE Drooping

SPEECH

Difficulty TIME TO CALL Emergency Number

ARM Weakness

Worldwide, cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability. (WHO, 2012)

Act F. A . S . T Save Lifes Albertus Alarik - Quinamora Estevan - Samuel Davin 228

Ready to ACTION Christian University of Krida Wacana Alega Greacia F, Farianti Wiranda, Jessica Amadea S, David Clinton N

Abstract Epilepsy is a chronic disease that has the characteristic form of recurrent seizures that often occur without triggers. This matter caused by central nervous system disorders due to excessive electrical brain activity patterns that cause seizures, sensations and unusual behavior, until loss of consciousness. Seizures are the main symptom of epilepsy, but not all people who experience seizures must have this condition. In Indonesia, there are an estimated 1.3-1.6 million sufferers of epilepsy. This number doesn’t describe the actual number of cases because many people don’t want to bring their family members that suffers from epilepsy to the health center or hospital for treatment. This happens partly because of the wrong stigma attached to epilepsy sufferers. Many people wrongly assume that epilepsy is a contagious disease. Which resulted more than 60 % sufferers don’t received the proper therapy. For those reasons, we provided 6 steps “ACTION”

that can help people to understand the emergency management to prevent the

mishandling in epilepsy patients who are relapsing. Keyword : epilepsy, seizures, emergency management

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Reference 1. Maryanti, N. (2016). Buletin Psikologi. Epilepsi dan Budaya, 24(1), pp.22-23. Available at: https://jurnal.ugm.ac.id/buletinpsikologi/article/download/16358/pdf 2. World Health Organization. (2019). Epilepsy in the WHO South-East Asian Region. Available at: https://www.who.int/mental_health/neurology/epilepsy/searo_report.pdf 3. World Health Organization. (2019). Epilepsy and seizures. Available at: https://www.who.int/mental_health/mhgap/evidence/epilepsy/en/ 4. World Health Organization. (2019). Epilepsy: the disorder. Available at: https://www.who.int/mental_health/neurology/Epilepsy_disorder_rev1.pdf

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BEAT the Stigma, HEAL Your Burn Trauma Aleyda Zahratunany Insanitaqwa, Aniq Roisatul Khikmah, Aulia Putri Fadriyana, Ridha Nugraheni Faculty of Medicine, Brawijaya University Burn injuries has become major global public health crisis. This devastating injuries is the fourth most common type of trauma worldwide (Peck et al., 2008). Moreover, WHO has estimated that every year, there are 180.000 deaths due to burn injury, and many of these occur in low-middle income countries. Burn injury can affect everyone, regardless of age, gender, education and socioeconomic status. Nonetheless, we still face some challenges, such as lack of the burn centre resources, trained providers and medicine supplies. The early phase in burns is a critical period. Inappropriate treatment during early phase of burn could lead to several complications, such as cardiogenic shock and hypovolemic shock which are life-threatening conditions. Therefore, people should know what to do and what not to do when having burn injury. However, in society, people do not understand yet the proper handling of burns. Some wrong beliefs are still used to treat the burn injuries which can cause further damage. Moreover, the understanding of how to manage burn injury properly is still lacking in societies. By this project, we hope that people takes a serious attention to this issues and be able to do first aid treatment of burn injury properly. References: Peck MD, Kruger GE, van der Merwe AE, Godakumbura W, Ahuja. 2008. Burns and fires from non-electric domestic appliances in low and middle income countries. Burns, 34(3):303-311. WHO. 2018. Burns, (online), (https://www.who.int/news-room/fact-sheets/detail/burns, accessed on September 30th 2019).

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SHIELD SOMEONE FROM CHOKING Alieftya Paramitha1, Shintya Kurniawati1, Muna Soraya1, Firyanadhira Imtiyasmi Syarifah1 1

Medical Faculty of Muhammadiyah University of Malang Abstract

One of unexpected thing we could encounter in daily life that is food choking. Choking is a disruption in the form of airway obstruction and has the potential to cause death if not treated immediately. Nowadays, there are still many people who still don’t know how to handle food choking properly. This skill must be known to many people, especially for a waiters who works in a restaurant that often interacts with customers. The rate is 11 to 13 cases per 100,000 per year, with male : female ratio of 1.7:1, resulting up to 1500 death per year. The method used to compile this poster is to search journal sources obtained through “Google Scholar”, “PubMed”, and “MedScape” search engine with "choking", "Esophageal food bolus impaction", and "heimlich maneuver" key findings.

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Dealing with Altered or Decreased Levels of Consciousness University: AMSA-Maranatha Christian University Authors: ●

Alyssa Feodora Ryanto

●

Pangastuti Retno Ardiningrum

●

Jerrick Lo Abednego

●

Romy Setiawan

1.1. Aim ●

To increase public awareness about patients with altered / decreased levels of consciousness

●

To minimise the number of patients with altered / decreased levels of consciousness arriving too late to hospital emergency rooms

1.2 Background From a small survey conducted to emergency room’s doctors, it has come to our attention that patients with altered / decreased levels of consciousness are often taken to the emergency room too late. Although signs such as; insomnia, lack of response, disorientation, etc. have been present for a few days or weeks before the patient is brought to the hospital, relatives or caretakers often underestimate it as only minor signs of illness. As such, a number of cases are present in which patients are brought in already at the later stages of consciousness. Thus, it is noted that raising public awareness on altered levels of consciousness is crucial in the field of emergency medicine. 1.3. Methodology ●

Survey We made forms regarding altered levels of consciousness for emergency room doctors from three different hospitals to fill as basis for our topic.

●

Library research We looked up information regarding diseases associated with altered levels of consciousness and its measuring scale.

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1.4. Key findings Out of 43 responses, 72.1% of doctors agree that the general public lack awareness on altered levels of consciousness. On a scale of 1 to 5, 5 being the most important, 35 of them put a 5 in the importance of the populace knowing this topic. In addition, 100% agree that the increase of public awareness on altered levels of consciousness will give a positive effect on emergency cases. Below are the top five diseases associated with altered levels of consciousness: 1. Stroke 2. Hypoglycemia or Hyperglycemia 3. Shock 4. Metabolic acidosis 5. Head trauma We decided to use the AVPU scale as basis for the grading of consciousness, as it is often used in emergency situations, but thought it would be wise to alter the wording in our poster so that it will be perceived better by the public.

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A s s e s a p e r s o n â&#x20AC;&#x2122;s l e v e l o f c o n s c i o u s n e s s u s i n g A V P U s c al e

Patients should be brought in

BEFORE

they speak incoherently (VERBAL)

d i s e as e s as s o c i at e d w i t h a lt e r e d l e v e l s o f co n s c i o u s n e s s :

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Snakebite Envenoming : Get to Know the First Aid Padjadjaran University Amalia Dwi M., Fathiyya Nabilah, Lita Latifah R., Raina Maharani T.

Aims To educate people about signs and symptoms and the treatment of victims of poisonous snake bites, including the first treatment and what should not be done which are important to increase victim’s chances of survival, decrease cases of disabilities, and prevent complications. Background Snakebite envenoming is a neglected public health issue in many tropical and subtropical countries. It is a potentially life-threatening disease that results from the injection of a mixture of different toxins following the bite of a venomous snake. About 5.4 million snake bites occur each year, resulting in 1.8 to 2.7 million cases of envenoming. Around 81.000-138 000 people die each year because of snake bites, and around three times as many amputations and other permanent disabilities are caused by snakebites annually. Snakebite epidemics follow flooding, cyclones and invasion of snakes’ habitats for road building, irrigation schemes and logging. Different snake venom can have a variety of effects ranging from localized pain to devastating complications. Research Methodology We gathered information through various books and Guidelines from the WHO, analyzed and summarized the informations to make them easily understood. Key Findings a. Sign and symptoms b. Epidemiology c. Dos and don’ts Sources: 1. WHO Guidelines on Snakebite

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2. Cook, G. C., Zumla, A. I., & Manson, P. (2009). Mansons Tropical diseases. Edinburgh: Saunders. 3. Jameson, J. L. (2018). Harrisons principles of internal medicine. New York: McGraw-Hill Education. 4. Snakebite

envenoming.

(2019,

April

8).

Retrieved

October

https://www.who.int/news-room/fact-sheets/detail/snakebite-envenoming 5. Current Medical Diagnosis and Treatment 2018

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2019,

from

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Got a snake bite? Do it the R.I.G.H.T way! Amelia Minarfah, Michelle Gracella, Lestari Eka Putri Wanti, Gita Safitri Faculty of Medicine, University of Jambi – Jambi, Indonesia

Aim: To increase public knowledge about snake bites and appropriate actions to deal with snake bites. Background: Morbidity and mortality occur most frequently among young people and children suffer higher case fatality. Many victims do not attend health centers or hospitals and instead rely on traditional treatments. Available data shows are 4.5–5.4 million people get bitten by snakes annually. Of this, 1.8– 2.7 million develop clinical illness and 81,000 to 138,000 die from complications. One the factor is that people keep seeking help through traditional medicine that oftentimes fail. So we would want raise people awareness to seek for medical help. Method : We used literature review by retrieved data from eligible sources, WHO. Key Findings: snake bite, appropriate action, medical help

References: WHO. 2016. Guidelines for the management of snakebites. Ed2. Link : https://www.who.int/health-

topics/snakebite#tab=tab_3

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Beat the Bite Anita Dominique1, Aileen Aurellia1, Gracyella Lorraine C.1, Andreas Dexter G.2 1

Second Year Medical Student, University of Brawijaya 2

Third Year Medical Student, University of Brawijaya

Chronic disability and death caused by venomous snakebites made snakebites an important medical emergency in many parts of SEA region. Not only those involved in farming and plantation work, but also the snake keepers themselves, are at the risk bitten by snake. In fact, 3 out of 5 snake keepers died due to their own snakes. Venomous snakes commonly share the same traits: triangular head, elliptical pupils, and large hollow fangs. Unfortunately, popular first-aid methods: sucking venom out, tying tight bandage at the bitten limb, applying topical products, and making local incision, do more harm than good. Recommended first-aid methods emphasize immobilization and immediate movement of the patient to the nearest health care facilities. Lastly, there are some ways to prevent snakebites, such as wearing boots and long trousers on risky area, such as grassy field; keeping your limbs away from unascertained holes; and using light especially in dark and after heavy rains (WHO, 2016). There are still plenty of cases not recorded due to inadequate reporting. Eventually, giving more concern to snakebites in Indonesia may reduce its incidence because everyone may be at risk of snakebites. KEYWORDS: Snakebite education, medical emergency

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Project Title

: Save Drowning Victim by FLOAT

University

: Universitas Airlangga

Authors

Arnindia Puspitasari

Bendix Samarta W

Clonia Milla

Lintang Elin M

Content : Drowning is suffocation from submersion in a liquid medium. In 2015, around 360,000 people died from drowning, making drowning a major public health problem worldwide. Drowning is the 3rd leading cause of unintentional injury death. Therefore, this poster promotes immediate actions needed to save drowning victim, which will help to reduce the death rate. In making this poster, it is hard to find literature review; however, it was found through the internet that AHA and WHO explained the steps to save drowning victims in emergency, which is named as “FLOAT” in our poster. The first step, F, “find out scene safety”, means that we need to check victim’s response. If the victim is unresponsive, do step L (“look for help via phone or nearby help”). Then, do step O, which means “operate C-A-B (chest compression-airway-breathing)”. Next, do step A (“AED has to be operated when available”). Lastly, do step T (“Try to check rhythm. If the pulse returns, yield recovery position. If it does not, repeat step “O””). All in all, emergency drowning victims can be saved through a few steps as written in this public poster. These steps have to be done carefully to provide maximum results. References : American Heart Association. (2015). Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation

Quality

–

ECC

Guidelines.

Retrieved

September

2019,

from

https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/part-5-adult-basic-life-support-andcardiopulmonary-resuscitation-quality/?strue=1&id=5-2 World

Health

Organization.

(2018).

Drowning.

Retrieved

https://www.who.int/news-room/fact-sheets/detail/drowning

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September

2019,

from

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High Five! Five Points to Survive Earthquake Background: Indonesia is geographically located at the confluence of 3 giant plates and ends up being rich of active fault distribution. This large number of faults can cause more than 10 earthquakes every day and 11,577 earthquakes every year (BNPB, 2018). However, the number of earthquake happened is not balanced with publicâ&#x20AC;&#x2122;s knowledge regarding the actions that must be taken when an earthquake occurs. Objective: The key factor to survive in dealing with disaster emergencies is by improving community preparedness and skill, which can begin with providing education about the appropriate response of the community. Here are five points to survive when earthquake occurs: 1. Don't panic and don't try to get out of the building to avoid injury caused by falling objects. 2. Stay protected by doing: drop to the ground, take cover by getting under a sturdy table, and hold on until the shaking stops. 3. Tap on a pipe or wall so rescuers can locate you. 4. Create a family emergency communications plan that has an out-of-state contact. 5. Stay away from buildings, beaches, and utility wires to avoid building collapse, potential tsunamis, and injuries when you are outside (Shake Out, 2017). Key Findings: Community preparedness, disaster response, earthquake preparedness, emergency situation. References:

Badan Nasional Penanggulangan Bencana. 2018. Panduan Kesiapsiagaan Bencana untuk Keluarga. Jakarta: Direktorat Kesiapsiagaan BNPB. Parlementaria. 2018. Tingkatkan Efektivitas Mitigasi Bencana. Jakarta: DPR RI Shake Out. 2016. Recommended Earthquake Safetyâ&#x20AC;&#x201C;Young Children and Infants. California: Earthquake Country Alliance. The Victoria State Emergency Service (VICSES). 2017. What to do in an Earthquake. Victoria: State Emergency Service. https://www.ses.vic.gov.au/get-ready/quakesafe/what-to-do-inan-earthquake (Accessed: September 30th, 2019)

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OVERACTIVE OR NOT, YOUR BRAIN IS AMAZING! A. Muh. Febrian Cakra; Annisa Ramadhanti Yusuf; A. Nur Syadza Ghalia; Ratri Indraswari Hasanuddin University, Makassar, South Sulawesi.

ABSTRACT About 65 million people across the world have active epilepsy. Epilepsy is a neurological condition characterized by “overactive” certain areas of brain, resulting in seizure. Seizure were a common emergency in public situation such as school and workplace. With the growing number of seizure’s incidence rate, there are still many misconceptions of seizure first aid management that people continue to hold. Lack of awareness and mis-management of seizure often results in endangering the patient’s life. Proper management of seizure will reduce the risk of status epilepticus – a prolonged seizure or more serious injury such as permanent brain damage. Through the public poster, we aimed to raise public awareness about the stigma related to seizure and to inform people the basic first aid of seizure.

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Do S.A.F.E for Anaphylaxis Universitas Kristen Krida Wacana Aurellia, Fanny Andy Setia Yanti , Sinta Iskandar Abstract The purpose of this poster is to educate for the readers on how to do an emergency treatment for anaphylaxis in a correct way.

There are seek for the nearest medical help, inject epipen (epinephrine

autoinjector), get an allergy diagnostic, and consult to a specialist to get a long term anaphylaxis treatment. If the epipen (epinephrine autoinjector) is prescribed, the patient and his or her closest people should be educated on when and how to use it so if the patient got the anaphylactic shock he or she could be saved. Anaphylaxis emergency treatment is very important for the society to know because anaphylaxis is a severe allergic reaction that can occur at any times and could lead to a shock that ended up to death. Shock is decreased tissue perfusion, or in other words decreased oxygenation of tissue. The symptoms of anaphylaxis are hives, itchiness all around the body, difficulty in breathing, nausea, diarrhea, low hypotension, swollen throat, eyes, and lips, dizziness, and stomach cramps. This poster is built based on the existing literatures. Key findings: Anaphylaxis, shock, epinephrine

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When Stroke Strikes Fast, Be Faster Than A Stroke Aim This poster aimed to make people learn and know about stroke and what to do when someone got stroke and hope to raise awareness among society about the danger of stroke and how a fast response is very much needed, exactly like for a heart attack case. Background Stroke has always been a major cause of death and disability in many countries. Stroke is an especially serious problem in Asia, which has more 60% of the world’s population, and many of its countries are “developing” their economies, such as Indonesia. While stroke risk increases with age, in these days society, stroke seems to strike a lot of younger people. Unfortunately, not that many people aware about how fast stroke can change their life. Brief Research Methodology NCBI Journal :JoS(Journal of Stroke) Stroke Epidemiology in South,East adn SouthEast Asia Official Website :The British Red Cross , World Health Organization American Stroke Association

Keywords Stroke;Emergency;Knowledge

Authors University of Jambi Ayushia Generosa Fakhri Dhea Anisa Yuri Lubis Tara Ayu Kinanti Hariyono Putri

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ALLERGY REACTION HAPPENED ?! BE HELPFUL WITH C.A.L.M Krida Wacana Christian University Azarya Sihite, Gea Pandanni Barth, Veronica Agrippina Franesta, Shindie Dona Kezia Lethulur

Anaphylaxis is an acute systemic reaction with symptoms of an immediate-type allergic reaction that can involve the whole organism and potentially life-threatening. The body produces antibodies called immunoglobulin E that attach themselves to certain cells, causing the cells to release a chemical called histamine that causes inflammation. Symptoms range from skin redness, hives and swelling in the most severe cases, vomiting, diarrhea, difficulty breathing. Severe reactions to environmental and food allergies can make a drop in blood pressure and anaphylactic shock may occur. Most people who develop adult-onset allergies usually do so in their twenties and thirties, though itâ&#x20AC;&#x2122;s possible to develop them at any age. Even following a successful diagnosis, avoiding trigger such food is difficult and accidental reactions are common. But even making an initial diagnosis is challenging. The main way to identify food allergies is for a patient to gradually eat increased amounts of that food under medical supervision. There is currently no cure for food allergy, and managing the condition relies on avoiding the offending foods and this writing aim how emergency treatment plan in case of exposure. That can achieve with c.a.l.m that stands for Call an ambulance, Assistance other in the right position to maintain airway, Lifesaving first and most important drug to give Epinephrine, Managing cardio-pulmonary arrest. If the cardiopulmonary arrest occurred do the CPR. Keywords: anaphylaxis, anaphylactic shock.

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Heat Stroke Universitas Pelita Harapan Catherine Siany Kurniawan, Stephanie Febria Lim, Fellisa Meliani, Shelvyana Heat stroke is a life-threatening medical emergency that is defined as a core temperature rise over 40Â°C, usually accompanied by central nervous system dysfunction. Heat stroke is an important condition contributing to mortality rate between 10-50% worldwide. Although the mortality rate is pretty high, heat stroke is largely preventable. Prompt recognition and immediate action by cooling through evaporation or full-body ice water immersion are crucial. These preventive measures can avert much morbidity and mortality associated with heat stroke. The aim of this poster is to raise public awareness about the importance to have early recognition and early management to prevent progressivity of heat stroke into a worse condition. Through this poster, we sincerely hope that the information will be delivered well so that public can recognize the symptoms of heat stroke, early diagnosis, and encouraged them to do the first aid. Reference: 1. Glazer, J. (2019). Management of Heatstroke and Heat Exhaustion. Retrieved 25 September 2019, from https://www.aafp.org/afp/2005/0601/p2133.html 2. Burt, A. (2016). Diagnosis and management of heat stroke. Anaesthesia Tutorial Of The Week, 341, 1. Retrieved from https://anaesthesiology.gr/media/File/pdf/WFSA_tutorial_341.pdf

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HEAT STROKE W WH HA AT T T TO O D DO O move the person into a cool place remove unnecessary clothing cool with fan or cold water apply ice packs give water if the person is conscious

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The Relevance of Raising Awareness of ARDS Emergency to Patients’ Chance of Survival Universitas Pelita Harapan

Cindy Clarissa, I Gusti Nadine, Shania Lokito

ABSTRACT

Acute respiratory distress syndrome (ARDS) is a rapidly progressive inflammatory disease

occurring in ill patients where complication may occur making it diﬃcult or impossible to breathe and cause loss of lungs function. This public poster aims to let people acknowledge the urgency of ARDS and how to treat patients to increase chances of survival. ARDS complication happens when fluid leaks from blood vessel to where blood is oxygenated, the alveoli. In ARDS, lung stiﬀness is increased and capability of lung to eliminate carbon dioxide is impaired. Sepsis, inhalation of harmful substances, and major chest injury may cause damage to the membrane that keeps the fluid from leaking, and major head injury may be the underlying cause of ARDS. Patients might have severe shortness of breath, rapid breathing, or chest pain during inhalation, resulting in severely decreased oxygen levels in blood and causing them to have cyanosis, making it an emergency case. The mortality rate of ARDS reached 40% in hospitals with the increase of severity overtime. ARDS patients require intensive care unit to prevent further complications and to maintain function of the lungs. Therefore, it is essential for people to acknowledge the management of this emergency case to improve patients’ chance of survival.

REFERENCES 1. Rezoagli, E., Fumagalli, R., & Bellani, G. (2017, July). Definition and epidemiology of acute respiratory distress syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5537110/.

2. Acute Respiratory Distress Syndrome (ARDS). (n.d.). Retrieved September 20, 2019, from https://www.lung.org/lung-health-and-diseases/lung-disease-lookup/ards/.

3. Respiratory Emergencies. (2006). doi: 10.1183/1025448x.erm3606

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ards.

ARDS or Acute Distress Syndrome ďŹ&#x201A;uid builds up in causing oxygen

Respirator y occurs when your lungs, deprivation.

know the 5 signs t o h e l p s av e a l i f e ! Retractions and the use of accessor y muscles to breathe. Inability to speak full sentences; 1 or two answers. Restlessness and declining level of consciousness. Inability to lie ďŹ&#x201A;at, or or thopnea. Extreme sweating, or diaphoresis.

About

40% of ARDS patients in hospitals do not sur vive.

So, cherish your lungs and prevent ARDS by: Flu Pneumonia

No smoking

No alcohol 261

Yearly vaccines

Adrenal Crisis: Stop Doubting Start Treating Damianus Galih Panunggal, Tithasiri Audi Rahardjo, Josephine Fiona Sucahyo, Resty Ayu Kumalasari Faculty of Medicine Diponegoro University, Semarang, Indonesia

Background Adrenal crisis is a medical emergency due to cortisol insufficiency, which commonly found in children with Congenital Adrenal Hyperplasia (CAH). CAH is a genetic disease when cortisol can’t be synthesized, leading to cortisol deficiency. There are approximately 20,000 estimated children with CAH in Indonesia, most of them are not recognized. Adrenal crisis accounts for 42% of death in CAH patients during their first year of life. In Indonesia, 12.8% of patients diagnosed with CAH died because of adrenal crisis. Failure to recognize symptoms of adrenal crisis and giving precise treatment can lead to preventable deaths. Parents with children having CAH should be aware if their children show symptoms such as vomiting, diarrhea, abdominal pain, and dehydration. During the crisis, the first aid and immediate hospitalization are vital for the patient’s survival. Drugs given by the doctor should be regularly taken, and patient compliance is essential to prevent an adrenal crisis. Aim: This poster aimed to increase CAH community awareness to reduce adrenal crisis mortality Methods Journal reading Key Findings Adrenal crisis, congenital adrenal hyperplasia, awareness, mortality Reference Yau M, Gujral J, New MI. Congenital Adrenal Hyperplasia: Diagnosis and Emergency Treatment. 2019 Apr 16. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279085/ Elshimy G, Alghoula F, Jeong JM. Adrenal Crisis. [Updated 2019 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499968/ Eur J Endocrinol. 2015 Mar;172(3):R115-24. doi: 10.1530/EJE-14-0824. Epub 2014 Oct 6. Sasigarn A. Bowden and Rohan Henry, “Pediatric Adrenal Insufficiency: Diagnosis, Management, and New Therapies,” International Journal of Pediatrics, vol. 2018, Article ID 1739831, 8 pages, 2018.

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in 1:13,000 to 1:15,000 live births Dörr, H. G., Wollmann, H. A., Hauffa, B. P., Woelfle, J., & German Society of Pediatric Endocrinology and Diabetology (2018). Mortality in children with classic congenital adrenal hyperplasia and 21-hydroxylase deficiency (CAH) in Germany. BMC endocrine disorders, 18(1), 37. doi:10.1186/s12902-018-0263-1 Falhammar, H., Frisén, L., Norrby, C., Hirschberg, A. L., Almqvist, C., Nordenskjöld, A., & Nordenström, A. (2014). Increased Mortality in Patients With Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency. The Journal of Clinical Endocrinology & Metabolism, 99(12), E2715–E2721. doi:10.1210/jc.2014-2957 Eyal, O., Levin, Y., Oren, A., Zung, A., Rachmiel, M., Landau, Z., … Weintrob, N. (2019). Adrenal crises in children with adrenal insufficiency: epidemiology and risk factors. European Journal of Pediatrics. doi:10.1007/s00431-019-03348-1 Utari A, Ariani MD, Ediati A, Juniarto AZ, Faradz SMH. Mortality Problems of Congenital Adrenal Hyperplasia in Central Java-Indonesia: 12 years experiences. Presented at the 9th biannual meeting of Asia Pacific Pediatric Endocrine Society (APPES) - 50th scientific meeting of Japanese Society for Pediatric Endocrinology (JSPE), Tokyo, 16-20 November 2016.

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Is She in GRAVE Danger? Author: Daniell Edward Raharjo, Vellia Justian, Felicitas Tania Elvina Universitas Indonesia Through a thorough literature review, it was discovered that cardiovascular disease is the leading cause of death for women, but only half of the female population is aware of this fact, attributing it as a ‘men’s disease’.1 Among cardiovascular diseases, acute myocardial infarction is leading cause of death in women worldwide.2 In the US every year, 450,000 women succumb to heart disease and 250,000, more than half, die because of coronary artery disease. This poor prognosis, especially compared to men, is due to failure to identify signs and symptoms of myocardial infarction, going unnoticed and unreported.3 Unlike the usual symptoms associated with heart attack by laymen, "tightness or discomfort of the chest", Women are more likely to experience symptoms such as gastric, jaw and back pain, rapid breathing, feeling of anxiety, vomiting and nausea, exhaustion and fatigue, and syncope or fainting, which are the less typical symptoms of myocardial infarction, but are more likely to occur in women.4 These symptoms are shortened into the catchy acronym “GRAVES”. Furthermore, although mortality is high, cardiovascular diseases are highly preventable through management of risk factors, such as departing from a sedentary lifestyle, weight control, alcohol and smoking cessation, controlling mental stress, maintaining a healthy blood pressure, along with reducing salt cholesterol and sugar 4 , which is abbreviated into the memorable acronime “SWAMPS”, hence our catchphrase: Avoid the GRAVES by staying out of the SWAMPS. Therefore, this public poster is meant to increase the awareness on this crucial issue in the community, which is lack of awareness on the different symptoms that is experienced by women during myocardial infarction, including the fact that not experiencing chest pain does not mean a heart attack is not happening.

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References: 1. Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA, American Heart Association Cardiovascular Disease and Stroke in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular Nursing, Council on High Blood Pressure Research, and Council on Nutrition, Physical Activity and Metabolism. Fifteen-year trends in awareness of heart disease in women: Results of a 2012 American Heart Association national survey external icon. Circulation. 2013;127(11):1254–63, e1–29. 2. Chandrasekhar J, Gill A, Merhan R. acute myocardial infarction in young women: current perspectives. International journal of women’s health. 2018;10:267-84. 3. Giardina EG. Heart disease in women. Int J Fertil Women. 2000;45(6):350-7. 4. Keteepe-Arachi T, Sharma S. Cardiovascular disease in women: understand symptoms and risk factors. European cardiology review. 2017;12(1): 10-13.

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A myocardial infarction is a condition where not enough blood is supplying the heart, causing cell death. This is usually caused by a blocka blockage of an artery from fatty plaque, leading to the common sign of chest pain.

GR A V E S

GASTRIC, JAW, AND BACK PAIN

RAPID BREATHING

Sedentary Lifestyle

ANXIETY

Weight

VOMITING AND NAUSEA

Mental stress Alcohol and Smoking

Mosca L, Hammond G, Mochari-Greenberger H, Towfighi A, Albert MA, American Heart Association Cardiovascular Disease and Stroke in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular Nursing, Council on High Blood Pressure Research, and Council on Nutrition, Physical Activity and Metabolism. Fifteen-year trends in awareness of heart disease in women: Results of a 2012 American Heart Association national survey external icon. Circulation. 2013;127(11):1254–63, e1–29. Chandrasekhar J, Gill A, Merhan R. acute myocardial infarction in young women: current perspectives. International journal of women’s health. 2018;10:267-84. Giardina EG. Heart disease in women. Int J Fertil Women. 2000;45(6):350-7. Keteepe-Arachi T, Sharma S. Cardiovascular disease in women: understand symptoms and risk factors. European cardiology review. 2017;12(1): 10-13.

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EXHAUSTION AND FATIGUE

Fats, Pressure Salt, Sugar

SYNCOPE OR FAINTING

LET’S DO “PENTA DON’T” When Epilepsy Seizure Attack Someone Egi Claudia Pratiwi, Meyustina Noviantika Sitohang, Virena Audelia Rambang Reza Rosita Magdalena from University of Palangka Raya ABSTRACT Epilepsy is a neurological disease characterized by seizures and can usually be accompanied by loss of consciousness. This disease affects approximately 50 million people worldwide (WHO 2018), while according to the Ministry of Health in Indonesia there are estimated to be around 1.3-1.6 million sufferers. Epilepsy or what is known in the wider community as "epileptic" disease often occurs around us. However, the lack of public knowledge in the first treatment of epilepsy sufferers who are experiencing an attack can worsen the condition of the patient. Based on these problems, made a public poster with the title "Let’s do" Penta Don't ". The purpose of making this poster is to educate the public to provide appropriate treatment for epilepsy sufferers who are experiencing seizures. Seizures are emergencies that must be handled appropriately so as not to endanger the patient's condition. Key words : Epilepsy, Seizure, Emergencies, Penta Don’t

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when epilepsy seizure attack someone

What is Epilepsy?

"Penta Don't" • DO NOT PANIC!

• DO NOT LET ANYTHING

WHAT COMMON EPILEPSY?

• DO NOT PUT ANYTHING • DO NOT TRY TO HOLD

wHAT ARE THE SIGNS AND SYMPTOMS?

• DO NOT FORGET

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The Importance of First Aid Awareness Universitas Pelita Harapan Elizabeth Marcella, Charlotte Alyssia Jonatan, Jeannette Tandiono, Michaela Kemuning Pusung Emergency is a sudden natural or man-made event in which immediate measures are required in order to avert a disaster. Emergencies can happen anywhere and anytime and it is one of the healthcare workersâ&#x20AC;&#x2122; duties to handle them. Even so, it doesnâ&#x20AC;&#x2122;t close the possibility of emergencies happening outside of the hospital or in unreachable areas where health services are scarce. That is why first aid is very important for everyone to know as some emergencies are very dire that actions taken on the first minutes of emergencies can mean life or death. First aid is emergency care or treatment given to an ill or injured person before medical aid can be obtained which intend to maintain airway and to support breathing and circulation. It is an essential skill everyone should have in order to lessen the complications and consequences of said emergencies. Cardiac arrest and choking are examples of two life threatening emergencies which are significant in global health, in which correct immediate management are paramount to prevent death and permanent disability. Therefore, first aid knowledge is crucial and very important. And yet, important as it is, the awareness of the importance of first aid in Indonesia is still low. Hence, this public poster is made to highlight and raise awareness of the importance of first aid knowledge. References: 1. Ronald, d. (2019). Pertolongan Pertama. [online] File.upi.edu. Available at: http://file.upi.edu/Direktori/FPOK/JUR._PEND._KESEHATAN_%26_REKREASI/PRODI. _KEPERAWATAN/197011022000121-HAMIDIE_RONALD_DANIEL_RAY/Bahan_Kulia h/pertolongan_pertama.pdf [Accessed 25 Sep. 2019]. 2. I.

(2019).

TINGKATPENGETAHUANTENTANGBANTUANHIDUPDASAR(BHD)

MAHASISWAFAKULTASKEDOKTERANUNIVERSITASUDAYANA. Simdos.unud.ac.id.

[online]

Available

at:

https://simdos.unud.ac.id/uploads/file_penelitian_1_dir/973304fec3de838114b0870bf7db fb40.pdf [Accessed 25 Sep. 2019]. 3. A.A.Ngirarung, S. and T. Malara, R. (2019). PENGARUH SIMULASI TINDAKAN RESUSITASI JANTUNG PARU (RJP) TERHADAP TINGKAT MOTIVASI SISWA MENOLONG KORBAN HENTI JANTUNG DI SMA NEGERI 9 BINSUS MANADO. [online] Media.neliti.com. Available at: https://media.neliti.com/media/publications/108532ID-pengaruh-simulasi-tindakan-resus itasi-ja.pdf [Accessed 25 Sep. 2019].

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4. Apps.who.int. (2019). DISASTERS & EMERGENCIES DEFINITIONS. [online] Available at: http://apps.who.int/disasters/repo/7656.pdf [Accessed 25 Sep. 2019]. 5. Dwi Pratiwi, I. and Purwanto, E. (2019). Basic Life Support: High School Studentsâ&#x20AC;&#x2122; Knowledge.

[online]

Ejournal.umm.ac.id.

Available

at:

http://ejournal.umm.ac.id/index.php/keperawatan/article/download/3934/4410 [Accessed 25 Sep. 2019]. 6. Rachmawaty S. GAMBARAN TINGKAT PENGETAHUAN MAHASISWA KESEHATAN DAN MAHASISWA NON-KESEHATAN UNIVERSITAS INDONESIA TENTANG TEKNIK RESUSITASI JANTUNG PARU (RJP) PADA ORANG DEWASA [Internet]. LIB UI.

2012

[cited

September

2019].

Available

http://lib.ui.ac.id/file?file=digital/20312327-S43469-Gambaran%20tingkat.pdf

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from:

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DROWNING KILLS YOUR FUTURE Emanuel Hananto1, Anastasia Meirina1, Hanna Melisa2, Andra Danika2 1

Third Year Medical Student, University of Brawijaya

Fourth Year Medical Student, University of Brawijaya

Drowning is a serious but neglected public health threat, with over 372,000 people die every year, making it the third leading accidental injury killer in the worldwide and among those are aged under 25 years, making it in the 10 leadings death for those ages. (WHO, 2014). Drowning is neglected because it doesn’t create any noise and it has a very fast killing speed, is estimated that it only takes 20 seconds for children to be drowned (USACE, 2018), That’s why it’s very easy to go unnoticed if someone is drowning. Therefore, prevention is the main key in fighting drowning. Prevention of drowning mainly consist of : provision of appropriate personal flotation devices, signage and designation of dangerous water bodies, appropriate boating and water regulation, close supervision of adults, as well as profesional adult supervision combined with reduction of exposure to water hazards through strategic barriers, swimming lessons on children and fast resuscitation in a timely manner by a trained observer or rescuer through mouth-to-mouth resuscitation and chest. If it is too late, call emergencies immediately. So, are you prepared to fight for your children? Because drowning kills your future.

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SUDDEN CARDIAC ARREST Fatimah Azizah Salsabila, Bellinda Zalzabilah Tazkira, Tatik Widiastuti, Monycha Helaina C. W.

Abstract 1. Aim : Analyzing cardiac arrest as a case of medical emergencies. 2. Background : Cardiac arrest is a condition of the heartbeat, heart function and blood vessels suddenly stopped marked by loss of consciousness and unable to breathe normally. The cause is a disturbance of the heart rhythm, precisely ventricular fibrillation so that the heart's ventricles only vibrate and also heart tissue injury, cardiomyopathy, and coronary arteries. Someone who is more at risk are smokers, obesity, diabetes, drug abuse, and excessive stress. Cardiac arrest is characterized by symptoms of palpitations, shortness of breath, and fatigue. 3. Brief Research Methodology : Checking the neck pulse and cardiac pulmonary resuscitation (CPR) to support blood circulation or cardiac massage with respiratory assistance. If available, use an automatic heart aid (AED) according to the procedure while waiting for an ambulance. At the hospital, doctors diagnose blood tests, X-rays, echocardiography and cardiac catheterization. Then, to prevent it, cardiac shock implant (ICD), ring placement, heart ablation, bypass surgery, and corrective surgery. 4. Keywords : Cardiac arrest, ventricular fibrillation, cardiomyopathy, pulse, and cardiac pulmonary resuscitation.

References : 1. Simanjuntak, Sugianto Parulian. (2015). “Sudden Cardiac Arrest dan Bulan Jantung Amerika”. Kompasiana, 26/06/15. 2. Fitria, Megawati. (2015). “Cardiac Arrest”. Kompasiana, 17/06/15. 3. Na’imah, Shylma. (2016). “Henti Jantung”. Hello Sehat, 12/03/16.

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Sudden Cardiac Arrest T

smoking

obesity

stress

diabetes HOW TO SAVE A LIFE?

Call the ambulance

Do the CPR 276

Shock with AED

ABSTRACT BEAT The Heat Fellicia Naurah Andryas, Cindy Jilbert, Alanis Maryjane Mamahit, Veriantara Satya Dhika Universitas Pembangunan Nasional “Veteran” Jakarta Indonesia will experience a temperature rise of 0.2 to 0.3°C per decade due to global warming. This condition can cause heat stroke, a core body temperature that rises above 40°C, accompanied by hot dry skin and central nervous system abnormalities. Heat stroke related deaths are expected to rise by nearly 2.5 times in the 2050s. Based on the presence or absence of exertion, heat stroke is classified into: 1. Exertional heat stroke that occur in healthy individuals executing rigorous physical activity. 2. Classical heat stroke which mostly affects the elderly with comorbidities including diabetes, obesity, and heart disease, even though high-level physical activities is not performed. Heat stroke patients present with dry skin, hypohidrosis even though their body temperature is 40°C or above, increased respiratory rate or shortness of breath, confused, unresponsive, even unconscious and seizure. Through our poster, we aim to increase awareness regarding the classification and the first aid of heat stroke. BEAT The Heat is an easy way to remember the essential steps needed to assist someone with heat stroke. B : Beep 112 E : Evacuate the patient A : Apply damp cloth or ice pack T : Take off unnecessary clothing

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References: Abdelmoety, D. A., El-Bakri, N. K., Almowalld, W. O., Turkistani, Z. A., Bugis, B. H., Baseif, E. A., … Abu-Shaheen, A. (2018). Characteristics of Heat Illness during Hajj: A Cross-Sectional Study. BioMed Research International, 2018, 1–6.doi:10.1155/2018/5629474 Awsassets.panda.org.

(2019).

[online]

Available

at:

http://awsassets.panda.org/downloads/inodesian_climate_change_impacts_report_14nov07.pdf [Accessed 4 Sep. 2019]. Bal, N., Meghna, P., Maurya, S. and Periasamy*, M. (2019). Increased incidence of heatstroke in India: Is there a genetic predisposition?. GERF Bulletin of Biosciences, 1(3), pp.7-17. Hifumi, T., Kondo, Y., Shimizu, K., & Miyake, Y. (2018). Heat stroke. Journal of Intensive Care, 6(1). Lim, C. (2018). Heat Sepsis Precedes Heat Toxicity in the Pathophysiology of Heat Stroke—A New Paradigm on an Ancient Disease. Antioxidants, 7(11), 149. Hifumi, T., Kondo, Y., Shimizu, K., & Miyake, Y. (2018). Heat stroke. Journal of Intensive Care, 6(1).doi:10.1186/s40560-018-0298-4 Nhs.uk. (2019). Heat exhaustion and heatstroke. [online] Available at: https://www.nhs.uk/conditions/heatexhaustion-heatstroke/ [Accessed 4 Sep. 2019]. Rowell LB. Cardiovascular aspects of human thermoregulation. Circ Res. 1983;52:367–9. Wu, X., Brady, J. E., Rosenberg, H., & Li, G. (2014).Emergency Department Visits for Heat Stroke in the United States, 2009 and 2010. Injury Epidemiology, 1(1), 8.doi:10.1186/2197-1714-1-8

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BEAT THE HEAT Mind These Signs!

Why Is this a Concern?

Know The Types!

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BASIC LIFE SUPPORT: A MATTER OF SECONDS Frederick Wirawan, Richard Pinarto, Trixie Nathania Zelig, Filza Salsabila Kamal Second Year Medical Student, Hasanuddin University

Basic Life Support is a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given fully medical care at the hospital. Well-known Basic Life Support procedures is CPR or Cardiopulmonary Resuscitation. Some of the situations that require CPR involve suffocation, near-drowning, cardiac arrest, and many more situation that can cause patients to stop breathing. According to American Heart Association, there are more than 350.000 cardiac arrest occur out of the hospitals. In Indonesia, it is estimated that there are 10.000 cases of peope who has cardiac arrest every year (Ahmad Lathif, et.al, 2017). However cardiac arrest can be handled with cardiopulmonary resuscitation. Fortunately, many places in Indonesia havenâ&#x20AC;&#x2122;t been conducted with the cardiopulmonary resuscitation. From the fact above, we want to encourage the nation about the importance of Basic Life Support and how we can prevent sudden death at the cause of cardiac arrest. At last, we hope that there will be an increasing number of people that understand by getting a training about Basic Life Support itself. Because Basic Life Support is a matter of seconds. Key Findings: Sudden Death, Sudden Cardiac Death, Cardiopulmonary Resuscitation, Basic Life Support

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Be Aware of the Dangers of Hypoglycemia Christian University of Krida Wacana Ghita Dea Fany S, Alega Greacia F

Abstract In Indonesia, there are an estimated 10.3 million people living with diabetes. Most of them are concerned with high glucose or hyperglycemia but few are aware of the danger of hypoglycemia or blood glucose levels are too low in diabetic patients. From the recent International Operations Hypoglycemia Assessment Tool (IO HAT) study in Indonesia, around 36.4% of patients did not know what hypoglycemia was at the initial symptoms. Hypoglycemia is a very dangerous condition where the blood glucose level is below the normal level or under 55 đ?&#x2018;&#x161;đ?&#x2018;&#x161;/đ?&#x2018;&#x2018;đ??ż .This usually happens due to an imbalance between food consumed, physical activity, drugs used. When a person suffers hypoglycemia, then he also suffers heart inflammation and increases the risk of atherosclerosis also change a person's heart rhythm. When hypoglycemia occurs continuously, then a person's heart rhythm will also experience changes constantly called arrhythmia. That can cause the heart pump canâ&#x20AC;&#x2122;t work optimally. Because the heart rate changes, diabetic patients who have complications of hypoglycemia often experience Long QT syndrome. This syndrome causes your heartbeat to be irregular and can cause sudden death. For those reasons, we discuss how to handle it to prevent the mishandling in hypoglycemia patients who are relapsing. Keyword : hypoglycemia, glucose, death

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Reference 1. Sutawardana, J. and Waluyo, A. (2016). NurseLine Journal. Phenomenology study the experience of persons with diabetes mellitus who had experienced of hypoglycemia episodes in depok city, Vol. 1 No. 1 Mei 2016 ISSN 2540-7937(No. 1). Available at: https://media.neliti.com/media/publications/197145-ID-phenomenology-study-theexperience-of-pe.pdf 2. Diabetes.org. (2019). Hypoglycemia (Low Blood Glucose) | ADA. Available at: https://www.diabetes.org/diabetes/medication-management/blood-glucose-testingand-control/hypoglycemia 3. Who.int. (2019). WHO | Preventing and treating hypogylcaemia in severely malnourished children. Available at: https://www.who.int/elena/titles/bbc/hypoglycaemia_sam/en/

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SEPSIS IS EMERGENCY Gita Safitri, Michelle Gracella, Amelia Minarfah, Lestari Eka Putri Faculty of Medicine, University of Jambi â&#x20AC;&#x201C; Jambi, Indonesia Aim : We purpose to increase public awareness and knowledge of sepsis. Background: The global epidemiological burden of sepsis is difficult to ascertain but it is estimated to affect more than 30 million people worldwide every year, even potentially leading to 6 million deaths. The burden of sepsis is most likely highest in low- and middle-income countries.1 While sepsis is more likely to affect very young children, older adults, people with chronic diseases, and those with a weakened immune system, sepsis is an equal-opportunity killer impacting people of all ages and levels of health. Therefore, it is important to raise publicâ&#x20AC;&#x2122;s awareness and knowledge of sepsis so they can find medical help as fast as possible and saves life. Method: We used literature review by collecting a few journals and data from eligible sources such WHO and CDC website. Key finding: sepsis, awareness, knowledge.

References: 1. WHO. 2018. Sepsis Fact Sheet. Link : https://www.who.int/news-room/fact-sheets/detail/sepsis 2. CDC.2017.How Can I Get Ahead of Sepsis. Link:https://www.cdc.gov/sepsis/prevention/index.html

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IS A MEDICAL EMERGENCY !!

P o t e n t i a ll y L e a d i n g t o 6 M i ll i o n D e a t h s

GET A MEDICAL HELP

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CALMING: First-Aid Management of Febrile Seizure in Pediatrics Irene Audrey Davalynn P1, Dwinanda Tsania1, Hanna Lianti Afladhia1 1

Faculty of Medicine, University of Indonesia

Aim: The study aims to promote and raise the awareness about the correct way of handling febrile seizures in pediatrics. Background: Febrile seizure is a seizure accompanied by fever, without central nervous infection. It’s the most common form of childhood seizures, affecting 2-5% of children between 3 months and 5 years of age.1,2 Febrile seizures considered benign and self-limiting. It’s a terrifying experience for the parents, and is one of the most common causes of trips to the emergency room. Parents feel anxiety, fear and shock when their child suffers a febrile seizure, many parents think their child is dying during a febrile seizure. This anxiety comes due to lack of knowledge about the event and how to handle seizure.3 Method: We did a literature search in Pubmed about febrile seizure, including the epidemiology, clinical signs&symptoms, and first-aid management. Key findings: From the literature findings, we made a comprehensive summary and an abbreviation of the first-aid management, in order to make it easily remembered by the public. The abbreviation is “CALMING”, which stands for: stay “Calm”, pay “Attention”, “Lay” on tilted position, give “Medication” rectally, don’t “Insert” anything in the mouth, don’t “restraiN” the movements, keep away from “danGerous” objects.

References: 1. Hageman J, Kelley K, Patterson JL, Carapetian SA, Hageman JR, Kelly KR. Pediatric Annals Proof Copy. 2013;(December). 2. Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs Context. 2018;7:212536. Published 2018 Jul 16 3. Sajadi M, Khosravi S. Mothers’ experiences about febrile convulsions in their children: A qualitative study. Int J Community Based Nurs Midwifery. 2017;5(3):284–91.

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Project Title : Early Detection and Management of Heart Attack Authors : 1. Jeanette Sefanya Yefta 2. Luigi Collins Aribowo 3. Michelle Joshaly Natasha 4. Richard Jefferson Krida Wacana Christian University Abstract : While the first leading cause of deaths in Indonesia is stroke, heart attack is the second, taking 138,400 lives every year. This totality depicts 8.9% of all deaths. Insufficiency nourishment, significant alcohol use, and high blood pressure are some of the rudimentary factors with this case. What makes heart attack fatal is it's potency to cause sudden deaths even in young and seemingly healthy person. With this public poster, we aim to grab public's attention to raise awareness on heart attack symptoms and inform how to manage them. We did our research by reviewing literatures (PubMed journals, American Heart Association's, and World Health Organization's website's contents). From the research we've done, we found out that the most important factor that determines the survival rate of heart attack is time. Every second counts when it comes to heart attack management. Thus, it's crucial to know the right and most efficient ways to spot and treat someone who's having a heart attack.

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Seize the Seizure Universitas Pelita Harapan Jesslyn Alvina Yapiter, Stephanie Esperansa Seizure can cause any changes in the brain’s electrical activity. Any seizure can lead to a dramatic, noticable symptoms or even without any symptoms at all. Severe symptoms of the seizure that are often recognized include violent shaking and loss of control.1 A recurrent seizure is identified as an epilepsy. Epilepsy is defined as having 2 or more unprovoked seizures while one seizures doesn’t signify an epilepsy.2 According to WHO, approximately 50 million people worldwide have epilepsy, which makes it one of the most common neurogical diseases globally. 80% of people with epilepsy live in low and middle income countries.3 From a systematic review and meta-analysis studies shows that the point prevelence of active epilepsy was 6.38/1000 persons (95% confidence interval 5.57-7.30). While the lifetime prevelance was 7.60/ 1000 persons (95% CI 56.69-81.03).4 Eventhough seizure happens occassionally, its still a taboo in some communities. Most people don’t even realize that it’s one of the most important emergency case worldwide, and with our poster we aim to waken people about the importance of this emergency5. Prevention of seizure includes identifying biomarkers of epileptogenesis in population at risk and prevent any head trauma or injury as well.6

References: 1. Wong, V., Stevenson, M., Mott, J., & Sahaya, K. (2019, April 1). Seizure and epilepsy publication in nonneurology journals. Retrieved from https://ohsu.pure.elsevier.com/en/publications/seizure-and-epilepsy-publication-innonneurology-journals. 2. Epilepsy. (n.d.). Retrieved from http://neurosurgery.ucla.edu/epilepsy. 3. Epilepsy. (n.d.). Retrieved from https://www.who.int/news-room/fact-sheets/detail/epilepsy. 4. Fiest, K. M., Sauro, K. M., Wiebe, S., Patten, S. B., Kwon, C.-S., Dykeman, J., … Jetté, N. (2017, January 17). Prevalence and incidence of epilepsy: A systematic review and metaanalysis of international studies. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27986877. 5. Home - PMC - NCBI. (n.d.). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/. 6. Schmidt, D., & Sillanpää, M. (2016, November). Prevention of Epilepsy: Issues and Innovations. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27628962.

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Fight Heart Attack With O.R.C.A. Observe – Recognize – Call – Act Universitas Pelita Harapan – Indonesia Justine Tanuwidjaja, Catherine Siany Kurniawan, Jocelyn Aurelia

Myocardial Infarction, also known as heart attack, is one of the leading causes of death in the world. The World Health Organization has estimated that 12.2% of worldwide mortality is caused by heart disease. Heart attack is a medical emergency that requires immediate hospital attention. Every minutes that passed can be a difference between life and death. The aim of this poster is to raise public awareness regarding how urgent heart attack is and how a quick recognition of the symptoms and early response could save someone’s life. Common symptoms such as chest discomfort, shortness of breath, light-headedness, and else, are easy to be recognize even for general public. Although not every heart attack will display the same symptoms, we hope by recognizing these symptoms, people can act more quickly and save someone’s life. We research the most common signs of heart attack and created an abbreviation to encourage the public to remember the signs and what to do in an emergency. We sincerely hope that our poster will help raise awareness for both the general public or even medical communities and perhaps save a life.

References: 1. Marcus G, Cohen J, Varosy P, Vessey J, Rose E, Massie B et al. The Utility of Gestures in Patients with Chest Discomfort. The American Journal of Medicine. 2007;120(1):83-89. 2. Awareness H. Heart Attack Awareness [Internet]. 2019 [cited 20 September 2019]. Available from: http://borderrac.org/heart-attack-awareness/ 3. Mendis S. Global progress in prevention of cardiovascular disease. Cardiovascular Diagnosis and Therapy. 2017;67(1):S32-S38. 4. Mehta P, Wei J, Wenger N. Ischemic heart disease in women: A focus on risk factors. Trends in Cardiovascular Medicine. 2015;25(2):140-151. 5. Heart attack [Internet]. nhs.uk. 2019 [cited 20 September 2019]. Available from: https://www.nhs.uk/conditions/heart-attack/

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HEART

F I GHT A T T A C K

DIZZINESS COLD SWEAT

SHORTNESS OF BREATH

CHEST DISCOMFORT

PAIN IN ARM OR SHOULDER

Have the person sit down, rest, and keep calm Loosen any tight clothing Ask if the person takes any chest pain medication and have them take it. 294

Bring Baby to a Whole New world with MAGIC Author : 1. Arlinna Rahmananda Yuliana Putri 2. Nindar Amelia Prabandari 3. Kasilda Pasha D* 4. Reynaldo Aryesta Oka Prastica

Background Obstetrics emergency can lead us to an increase in Maternal Mortality Rates (MMR), which is a health issue that is still a concern lately. In developing countries MMR are still relatively high, for example in 2015 Indonesia reached 126/100.000 births, India 174/100.000 births, and Vietnam 54/100.000 births. Many of Obstetrics emergencies are triggers due to the ignorance of society about the sign and symptom of the mother who will give birth. Here we make the shortening of the sign and symptom of labor named "ALADIN" which will make it easier to remember. Increase of MMR are also contributed by several complication as we mentioned in the poster. In order to help the government to reduce MMR, we made a secret formula to prevent Obstetrics emergency that we called it “MAGIC”. We all hope that “MAGIC” could bring mothers and their baby to a whole new world that can helps decrease MMR. Aim In the end our poster is about how to recognize the sign and symptom of labor, complication and the prevention to prevent Obstetrics emergency. Methods We use systematic reviews of cross sectional studies that listed in references. Keyword Obstetrics Emergency, MMR ( Maternal Mortality Rate), ALADIN, MAGIC.

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References 1. Better Heatlh Channel. 2018. Pregnancy – Obstetric Emergencies. 2. Sulistiyowati, Ning., Sari, Puti., dan Hapsari, Dwi. 2017. Kesinambungan Pemanfaatan Pelayanan Kesehatan Maternal di Indonesia. 3. The American College of Obstetricians and Gynecologists FAQ004. Labor, Delivery, and Postpartum. 4. UNICEF. 2015. “Maternal and Newborn Health Disparties Indonesia”. 5. WHO. 2015. “Maternal Mortality in 1990-2015 India”. 6. WHO. 2015. “Maternal Mortality in 1990-2015 Vietnam”. 7. WHO. 2015. “Pregnancy, Childbirth, Postpartum and Newborn Care”. 8. WHO. 2017. “Managing Complications in Pregnancy and Childbirth”.

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Signs & Symtomps

Complications of Emergency Obstetric

M A G I C 297

Maintain ANC & do regular exercise Arrange the pregnancy interval Get healthy & nutritious food Identify signs and symptoms Control for Post Natal Care & keep your hygiene

â&#x20AC;&#x153;How to Overcome Asthma with STEADYâ&#x20AC;? (La O. N. A. Syahnasti, Lilyana A. Ahmad, Siska N. Anggraeni, Zaenab N. H. B. Sukirman ) Medical Faculty of Haluoleo University Southeast Sulawesi Indonesia

ABSTRACT Indonesia now a days occupied the world number five of the highest number of Asthma, and world number thirteen of the country with the most death due to asthma. Based on 2013 Basic Health Research data shows about 1 in 22 people suffer from asthma. However, only 54% were diagnosed whilw only 30% were well controlled. The factors that cause this issue is the level of public awareness of asthma in Indonesia is still low. The lack of diagnosis and therapy facilities also took part of this issue. In severe cases, asthma attacks can be very dangerous because it causes an obstruction or blockage of the airway that might lead to dead condition. Therefore, it is important to recognize the clinical symptoms to prevent asthma attacks. Generally, asthma symptoms such as coughing, shortness of breath, wheezing or breathing is accompanied as a whistle. The recurring symptoms (relapse) when a person is exposed to a stimulus or trigger factors of asthma relapse, and become heavy at night and early morning. Asthma itself is one form of allergy. The respiratory tract become more sensitive to stimulan or triggers. If it makes some contact with the originator, respiratory tract narrowed so that a person can experience breathlessness that can lead to death if not treated properly. With the dangerous of asthma disease, compounded by a lack of public understanding to handle this cases, so we need to share some process of education and socialization to the community how the initial treatment of asthma. Because we can save one life with share our knowledge. Keywords : Allergy, Asthma, Asthma Treatments

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SWIM ABC: Guide to First Help in Drowning Lintang Cahyaning Ratri, Dwiastri Iris Sarwastuti, Nadine Natasha Iskandar Background In learning how to swim, one also need to learn how to avoid drowning and how to help someone whoâ&#x20AC;&#x2122;s drowning. Steps for helping a drowning person have been comprised to SWIM ABC to make it easier to memorize. S stands for see, meaning while swimming both at sea or pool, one needs to keep alert of any drowning victim. W stands for warn, meaning one who's helping must warn others, tell them that s/he is about to help, and ask them to call for help (ambulance). I stand for isolation, meaning the helper will isolate both him/herself and the victim from any potential danger, including water. M stand for measure, meaning after making sure that the surrounding is safe, the helper must measure the patientâ&#x20AC;&#x2122;s level of awareness and any visible damage/wounds. Afterwards, helper should check 3 main vital signs which are Airway, Breathing, and Circulation (ABC). Aim To educate people the crucial steps in dealing with drowning To promote SWIM ABC as a way to remember the procedure easily Brief Research Methodology Literature review from existing articles about first aid help and mix different steps from different source. Key Findings: Drowning, swim, water emergency Reference: Oakley,

L.,

2017.

Available

at:

British

Red

Cross.

[Online]

https://blogs.redcross.org.uk/first-aid/2017/07/five-things-you-should-

know-about-drowning/ [Accessed 29 September 2019]. Robinson,

J., Available

2017. at:

Drowning

Treatment.

[Online]

https://www.webmd.com/first-aid/drowning-treatment

[Accessed 29 September 2019].

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See the ALERT, be the expert! Authors : Madeline Belda, Kareen Tayuwijaya, Medhavini Tanuardi Universitas Indonesia

Abstract: Aim: To raise the survival probability of food-choking victims by educating people regarding the immediate action needed to help in the easiest ways possible. Background: Choking has killed approximately 5.200 persons in Unites States (Elflein J, 2019) and ranked fourth from the causes of unintentional injury death according to National Safety Councilâ&#x20AC;&#x2122;s injury fact in 2017 (Duckett & Roten, 2019). At least 1 child dies every five days from food-choking in the United States (Department of Health New York State, 2017). Death caused by choking is usually because of poor management. However, this problem can be solved by educating the public on the symptoms and maneuvers that can be used to deal with it. Around 95% of choking deaths happen at home (Chappin MM et al, 2013) so we should always be prepared whenever we encounter the event of choking to avoid losing our dear ones because of it. Brief Research Methodology: We conduct a research based on journals and governments' prevalence statistics online. From the studies, we found that choking is an unpredictable cause of death but also preventable. Key findings : Food-choking, Abdominal Thrust References: Chapin MM, Rochette LM, Annest JL, Haileyesus T, Conner KA, Smith GA. (2013). Nonfatal choking on food among children 14 years or younger in the United States, 2001-2009. Ohio: The Research Institute at Nationwide Childrenâ&#x20AC;&#x2122;s Hospital. Retrieved from: https://www.ncbi.nlm.nih.gov/m/pubmed/23897916/ Department of Health New York State. (2017). Choking Injuries and Deaths are Preventable. New York: New York State. Retrieved from: https://www.health.ny.gov/prevention/injury_prevention/choking_prevention_for_children.html Duckett SA, Roten RA. (2019, January). Choking. Treasure Island (FL): StatPearls Publishing. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK499941/ Elflein, J. (2019, August 14). Number of choking-deaths in the U.S. 1945-2017. Retrieved from : https://www.statista.com/statistics/527321/deaths-due-to-choking-in-the-us/ National Health Service. (2018, August 21). what should I do if someone is choking. Retrieved from : https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/what-should-i-doif-someone-is-choking/

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Drowning: What to Do and How to Help Malikulsaleh, Salma Firdaus, Alif Raihan Laksono, Hanif Ardiansyah Airlangga University

Background Drowning, as defined by World Congress on Drowning 2002, is a process of experiencing respiratory impairment from submersion/immersion in liquid. On its official site, World Health Organization stated that drowning, surprisingly, is the 3 rd leading cause of unintentional injury death worldwide as well as caused roughly about 372,000 deaths per year. In South East Asia region, drowning is 2nd leading cause of death of 10-14 years old children (WHO, 2014). While more than 90% of the accident happened in low and middle income countries (WHO, 2014) where not only the socioeconomic but also the level of knowledge is arguably lower than developed countries, it is well understood that any insight about drowning, either how to overcome the situation or what kind of things that help the most are necessary and could be a life saver. Using this poster, we hope this information could be shared and later could be used to save more life. Objectives 1. To promote ‘SWIM’ and ‘HOLD’ as an easy-to-remember acronym of safe steps related to drowning 2. To encourage public to learn then to have a courage for using those steps to save not only their own life, but also others. References World Health Organization. 2014. Global Report on Drowning Preventing a Leading Killer. ISBN: 978 92 4 156478 6.

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Severe Dehydration Universitas Pelita Harapan Marlyn Suciningtias, Audrey Hadisurya, Celine Chrystelle, Fenia Tandy Dehydration is a condition when an individual loses more liquid than they are taking in. There are 3 stages of dehydration: mild dehydration, moderate dehydration, and severe dehydration. In Mild and Moderate dehydration, drinking water or other fluids such as electrolyte is enough to help our body rehydrated. But in Severe dehydration we need medical help to rehydrate our body. Severe dehydration is a serious condition where someone needs medical intervention as soon as possible to prevent organ damage, such as kidney and liver, and other various dire complications, including death. Babies are at greater risk of developing dehydration. Babies can lose water through a wide variety of causes, one of the most common form is through vomiting and diarrhea. It is recorded that dehydration by diarrhea is one of the biggest single killers of children in the modern world, among children aged 28 days to five years, 1.7million of 6.6million, equal to 26% of deaths each year are caused by diarrhea. The initial symptoms of severe dehydration on babies are rapid and deep breathing, fainting, sunken dry eyes, sunken fontanelle, dry mouth, dark yellow pee, and cold hands and feet. Take your baby to the general practitioner immediately if these symptoms appear. This public poster is made to raise awareness and prevent severe dehydration on babies in the future. References: 1.

nhs.uk. (2019). Dehydration. [online] Available at: https://www.nhs.uk/conditions/dehydration/ [Accessed 29 Sep. 2019].

Living-Water. (2019). The Different Stages of Dehydration. [online] Available at: https://www.livingwater.co.uk/blog/the-different-stages-of-dehydration/ [Accessed 29 Sep. 2019].

Robert Ferry Jr., F. (2019). Dehydration in Children: Symptoms, Signs, Causes & Treatment. [online] eMedicineHealth. Available at: https://www.emedicinehealth.com/dehydration_in_children/article_em.htm#what_causes_of_dehydration_in_children [Accessed 29 Sep. 2019].

Rehydrate.org. (2019). Dehydration: Why It Is So Dangerous - Diarrhoea, Diarrhea, Rehydration. [online] Available at: https://rehydrate.org/dehydration/ [Accessed 29 Sep. 2019].

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SEVERE DEHYDRATION HAVE YOU CHECKED ON YOUR BABY YET?

DEHYDRATION

SIGNS AND SYMPTOMS

occurs when there isn’t enough fluid in the body to keep it working

properly. Young children and babies are at greater risk of becoming dehydrated than adults.

Fever

Sweating

MAIN FACTORS

Severe Vomiting

Severe Diarrhea

WHAT TO DO ? Giving your babies fluid to drink,such as WATER or BREASTMILK

FACTS ABOUT SEVERE DEHYDRATION

It is recorded that among children aged 28 days to five years, 1.7million of 6.6million, equal to 26% of deaths each year are caused by diarrhea. ( rehydrate.org )

STAY

Very dry mouth Sunken eyes Cool and discolored extremities No peeing for 8 or more hours Deep and rapid breathing Sunken soft spot on top of an infant’s head Dry or wrinkly skin Inactivity or decreased alertness

CALL FOR HELP !

HYDRATED 307

GIVING PAMPERS FOR INFANT Moh. Iqbal Irsyad Al Zaman, Elfindri Okgandita Veranie, Izza Amalia Putri, Nadiyya Dzawil Ma'la Universitas Jember

ABSTRACT First aid in emergency cases is something which can reduce or even save a person's life, especially in infants unable to do first aid without the help of others. The psychosexual phase that they experience indirectly leads the infants to actively find out everything that they encounter, and put it in the mouth, which is known as the oral phase. According to World Health Organization (WHO) in 2011 about 17.537 cases of choking are common in 18-36 months of infants. Therefore, telling people how to handle choking is really needed to be known by everyone, especially parents. With increasing knowledge about choking, the symptoms shortened to "infant" and treatment shortened to "pampers", it is hoped that cases of choking in infants can be treated immediately and do not cause complications and do not cause deaths. Research methodology is carried out by examining various reliable journals regarding choking cases. Keywords: infant, choking, pampers, oral phase

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Stroke: Not Just About a Disease, Its About Quality of Life Muna Soraya 1, Muhammad Ridho 1, Radya K. Ardianto 1 1

Faculty of Medicine, University of Muhammadiyah Malang

Aim

: Increase awareness about stroke and how to prevent it

Background

: Health is a good condition of physical, mental, and social, which leads to human’s quality of life. Unfortunately, some diseases can reduce it, and stroke is one of them. Stroke is defined as a cerebrovascular accident which is a major cause of morbidity and mortality in many countries. In fact, the prevalence of stroke in Indonesia increased initially from 7%, in 2013, to 10.7% in 2018, while in SouthEast Asia there are 4.5 million people affected by stroke. Still in 2018, stroke has reached 30.7 million people worldwide. Obviously, this is not a small number, hence stroke has to be prevented. This poster is aimed to increase the awareness of stroke and how to prevent it. A search was conducted in PubMed with the search terms used were “stroke” with the operator “and”, along this following terms: “prevalence”, “risk factors”, “prevention”.

Key Finding

: Stroke, Prevalence, Sign and Symptoms of Stroke, Prevention

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HUG ME TO SAVE ME Nadhilah Farisah; Andi Anugerah Sahrany; Da’watul Khair; Nurul Fadhiah Alissa Hasanuddin University, Makassar, South Sulawesi. ABSTRACT Choking occurs when there is foreign matter, food, or fluid that is blocking the respiratory tract or air flow in the throat. But usually the most common is when choking at mealtime. Usually, there are many people directly giving a drink to the person who is choking. But this is a wrong thing because by giving a drink, can make food enter the deeper respiratory tract. People around our environment should be given more education about how to deal with people who are choking on food. The first step that must be done to remove the foreign object in the respiratory tract: -

ask to “ coughing forcefully” until the foreign object comes out.

if a person who’s choking can’t cough, do five-and-five” method ( Hit the person’s back with the heel of your hand five times between the shoulder blades). Next, perform “Heimlich maneuver” five times (stand behind the person who coke, wrap both wist below the person's rib cage. with both hands holding each other, give upward and inward thrust to he/ she.). This poster aimed inform people to take appropriate emergency actions to help people who choke,

avoiding death due to choking, especially because of food.

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FANTASTIC for Choking Natasya Ariesta Sellyardi Putri, I Made Agus Dwipayana, Faida Ufaira Prameswari, Hersati Prasetyo Faculty of Medicine, Universitas Airlangga Background: Choking is one of the most common phenomenons found in daily life. It can be caused by food, asthma, inhalation of various toxic substances or particles, and even neurological factor like stress-induced choking. This incident took 5,051 people to die in 2015. Furthermore, a child dies from choking on food every five days in U.S. Choking needs to be quickly done since it blocks the airway which can lead to death. Methodology: Literature Review Aim: Occurrence of choking can be prevented and treated by people. Based on literature review taken, choking mainly happens when eating, so sitting up straight, don’t rush when eating, cut the food into small pieces, chewing food thoroughly, and less talking are important. Choked people can be recognized by bluish skin, cough, and difficulty breathing. If it is happening, they can be asked to cough, helped by back blows or Heimlich maneuver (above 1 years old), CPR if unconscious, and by calling ambulance (119 for Indonesia, 102 for India) which are easier to be remembered with FANTASTIC. Key finding: Decreasing the death case caused by choking; Signs of choking; How to prevent choking; How to treat choking

REFERENCES: Department of Heath of New York, 2017, Choking Prevention for Children, available at <https://www.health.ny.gov/prevention/injury_prevention/choking_prevention_for_children .htm> downloaded on September 28th 2019. Guo, Bingxin, Bai, Yichun, Ma, Yana, Liu, Cong, Wang, Song, Zhao, Runzhen, Dong, Jiaxing, Ji, Hong-Long, 2019, “Preclinical and cinical studies of smoke-inhalation-induced acute lung injury: update on both pathogenesis and innovative therapy”, Therapeutic Advances in Respiratory Disease, available at <https://jpurnals.sagepub.com/doi/pdf/10.1177/175346661 9847901> downloaded on September 28th 2019. Mayo Clinic, 2017, Choking: First aid, available at <https://www.mayoclinic.org/first-aid/first-aidchoking/basics/art-20056637> downloaded on September 28th 2019.

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National

Safety

Council,

2019,

Choking

Prevention

and

Rescue

<https://www.nsc.org/home-safety/safety-topics/choking-suffocation>

Tips,

available

downloaded

at on

September 28 2019. Yu, Rongjun, 2015, â&#x20AC;&#x153;Choking under pressure: the neuropsychological mechanisms of incentiveinduced performance decrementsâ&#x20AC;?, Frontiers in Behavioral Neuroscience, available at <https://www.frontiersin.org/articles/10.3389/fnbeh.2015.00019/full> September 28th 2019.

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downloaded

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The Emergency of Choking Universitas Pelita Harapan Nivia Permatasari, Klarasita Wibowo, Naomi Rachel Ivania Choking is an acute internal blockage of upper respiratory passage into the trachea by a solid foreign object. According to Injury Facts in 2017, choking is the fourth leading cause of unintentional injury death. There were 1.6 deaths from choking per 100.000 populations. These datas indicate that choking is a remarkably serious problem and that leads to our aim of making this public poster which is to educate people about the emergency management of choking until such time as we realized that the awareness of choking has to be raised within the community. Choking with a complete blocked airway may lead to oxygen deprivation or asphyxia which eventually can lead to death. The brain is extremely sensitive to this lack of oxygen and begins to die within four to six minutes. In this very crucial time, emergency medical teams may not arrive in time to save a choking person's life. Therefore, it is truly important for everyone to understand and be capable of managing this particular condition as it can lead to irreversible brain death in the span of 10 minutes. References: 1. K, M., & P, S. R. (2015). A Review Article on Choking. International Journal of Research in Health Sciences, 3(3), 403â&#x20AC;&#x201C;406. Retrieved from http://www.ijrhs.org/sites/default/files/ IntJResHealthSci-3-3-403.pdf 2. Safety at Home. (2016, February 25). Retrieved from https://www.nsc.org/home-safety/safetytopics/choking-suffocation 3. Duckett, S. A., & Roten, R. A. (2019, April 9). Choking. Retrieved from https:// www.ncbi.nlm.nih.gov/books/NBK499941/

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CALL

SS M M TTOO P P M M SSYY GASPING

911

DID YOU KNOW? In 2017, choking is the

COUGHING GAGGING BLUISH

COUGH

ASK THE PERSON TO COUGH IF THE OBSTRUCTION DOESN'T COME OUT, DO STEP 2

leading cause of unintentional injury death.

There were 1.6 deaths from choking per 100,000 population.

SLAP

DO BACK BLOWS 5 TIMES IF THE CHOKING HAS NOT RESOLVED, DO STEP 3

THRUST

MAKE A FIST PLACE IT ABOVE BELLY BUTTON

BELOW RIBCAGE

HEIMLICH MANUEVER

)

))

C CH O K I N G ?

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Project Title

: 112 Only One Call Away

Authors

: Puspa Gracella Tambunan, Theodorus Wijaya, Josephine Alicia Bierhuijs Universitas Tarumanagara

Aim: to educate the society about how to deal with daily emergency situations in daily life. Background/Introduction: Emergency medicine is the medical specialty dedicated to the diagnosis and treatment of unforeseen illness or injury. The practice of emergency medicine includes the initial evaluation, diagnosis, treatment, coordination of care among multiple providers, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care. But, the success of medical emergency services does not only depend on the ability of the medical crew, but also requires responsiveness from the family or the people who are around the patient when the emergency occurs. However, the most common society are lacking in understanding about how to respond to daily medical emergencies: steps and who is to contact at the time. Thus, it is important to educate the public on this matter, one of the ways is through a public poster. Research methodology: We conduct a comprehensive study and interpret the literature that adresses the topic of daily medical emergencies in the community and illustrate the information in a way that is easier for the community to understand through a public poster. Key findings: emergency medicine, daily medical emergencies, respond, society, community, steps, emergency contact

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O N LY O N E CA LL AWAY

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DO SAFE TO SAVE A LIVES ABSTRACT Raditya Widya Surianata, Salshabilah Azzahra Raswhita, Pravica Juti Arunasari University of Muhammadiyah Malang, Indonesia Currently, traffic accident becomes the main killers of humans with an age range of 5 to 29 years in the world. According to WHO, there are 750.000 deaths per year due to traffic accidents in 24 Asian countries. This condition makes first aid very important to do because it can affect the victim's condition afterward. Many people do first aid but don't understand how to do it properly then end up makes the victim's condition getting worse or even death. The wrong things that often during first aid are such as give the victim's water can cause choking, immediately moves the victim's body that has a serious injury can worsen the injury and many people surrounds the victim's body makes victim's lack of air. However, SAFE are the simplest things to do during first aid: Seek for help (call ambulance or nearby doctor), Avoid the crowd from the victim, Find pulse from the victim, and Ease the airway by not giving food or water.

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Importance of Anaphylactic Shock Awareness Universitas Pelita Harapan Regan Elbert, Laurencya Stephanie Rusli, Jennifer Jesse Limanto, Griffin Geraldo Every person has their own unique allergens. This leads to unending and various combinations of substances that could make each person go into a serious allergic response. The allergic response may be varying, from hives, rashes, to systemic allergic response such as anaphylactic that could lead to a deadly shock caused by flooding of cytokines in our body. When people get into anaphylactic shock, the outcome may be fatal. But, we can minimize the complications of the disease by giving first aids to reduce the symptoms and prevent further damage. Through this public poster, we aim to educate and raise the awareness on how to give first aid for emergency conditions such as anaphylactic that could lead to anaphylactic shock. From the references, we have combined and assessed the objective for the public to recognize and give adequate first aid for people having anaphylactic conditions in a simple way. Hence, though this project, we also raise the awareness of how life-threatening the anaphylactic conditions are that could lead to death. References : 1. Anaphylaxis. (2018, November 14). Retrieved from https://acaai.org/allergies/anaphylaxis 2. Anaphylaxis: AAAAI. (0AD). Retrieved from https://www.aaaai.org/conditions-andtreatments/allergies/anaphylaxis 3. Jameson, J. L. (2018). Harrisons principles of internal medicine. New York: McGraw-Hill Education. 4. Tintinalli, J. E. (2019). Tintinallis Emergency Medicine: a comprehensive study guide. S.l.: MCGRAW-HILL EDUCATION.

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ANAPHYLACTIC SHOCK

Us a sErio S i s i X la ic AnapHy aLlerG e r e H ion w e cOndiT omE lIf c E b s n rEactIo esE Ng. Th i n e T a Y tHre AuseD b c E b y ns mA rEactIo TingS, s T c e s iN fOods, oTher d N a , s tioN mEdicA ens. aLlerG

what can you do?

1 2 3

4 5

sEverE aLlerGic rEactIons rEsulT iN dIlatIon oF bLood vEsseLs wHich lEads tO:

sTomaCh cRamp & vOmitIng

rEmovE aLlerGen cAll fOr hElp eLevaTe tHe lEgs

ePinePhriNe pEn gIve cPr wHen cIrcuLatiOn iS aBsenT

dIzziNess oR fAintIng

hIves

SwelLing oF mOuth, tOnguE aNd tHroaT bReatHing dIffiCultIes oR wHeezIng 324

Time is Muscle : Act now before itâ&#x20AC;&#x2122;s too late Universitas Indonesia Reynardi Larope Sutanto, Dara Ariqah Jibril, Mochammad Izzatullah Acute coronary syndrome or heart attack is one of the cardiovascular life-threatening diseases due to atherosclerosis plaque. The plaque is formed in the coronary artery causing a sudden decrease in blood flow to the heart. People with ACS usually feel a discomfort in their chest and the pain radiates until neck, left arm, and lower jaw. The issue of acute coronary syndrome is categorized in emergency medicine as time is very important factor that influences patientâ&#x20AC;&#x2122;s prognosis. In order to reduce the time delay to treatment, there is one term among the physician called the total ischaemic time (TIC). TIC is the maximum time needed in order to treat the ACS patient. Therefore, bringing patient as soon as possible before the TIC runs out is very important. When the patient feel the symptoms of chest pain, surrounding people must call an ambulance immediately or bring him or her to the nearest clinic or hospital. Because medical personnelles are not usually found near a person having a heart attack, we conclude that the public needs to know the importance of getting help as soon as possible for the survival of heart attack patient

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Heat Stroke Can Kill You! Sandro Ruberto, Mardelia Nur Fatana, Shiany Henly Citraminata Faculty of Medicine, Diponegoro University Corresponding e-mail : ruberto.sandro@gmail.com, 21mardelianurfatana@gmail.com, shianyhenly@gmail.com ABSTRACT Background : One of the 3 leading causes of sudden death in sports activities is heat stroke.[2] This emergency condition is caused by extreme elevation of body temperature (higher than 40Â°C /104Â°F) which may cause cellular damage after 30 minutes or so of elevated temperatures.[1][5] Heat stroke kills hundreds of people in United State, data shown in 2015, 335 lives were killed , according to the Centers for Disease Control and Prevention.[2][6] While, in India, mortality incidence has risen by 5 times from 2001 to 2015. Athletes, outdoor workers, infants, and the elderly are more prone to have a heat stroke. Sign and symptoms of heat stroke are hot, red, lack of sweating, throbbing headache, rapid heartbeat, and muscle cramp.[4] An uncontrolled extreme elevation of body temperature alters body function which leads to sudden death.[1] Therefore it is important to know the initial treatment that could be done as pre-hospital emergency care : move to shady spot, call emergency medical help, rehydrate, loose lifting cloth, cool water spraying, must be performed to reduce mortality rate.[3] Aim : To raise public awareness of the sign and prevention of heat stroke to reduce the incidence of death. Research Methodology : We collected journal published during 2015-2019 related to this topic. Keywords : Heat stroke, emergency, outdoor, dehydration Reference : 1. Ferri FF. Heat exhaustion and heat stroke. In: Ferri's Clinical Advisor 2017. Philadelphia, Pa.: Elsevier; 2017 2. O'Connor FG, et al. Exertional heat illness in adolescents and adults: Epidemiology, thermoregulation, risk factors, and diagnosis.

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3. Extreme heat: A prevention guide to promote your personal health and safety. Centers for Disease Control and Prevention. 4. Mechem CC. Severe nonexertional hyperthermia (classic heat stroke) in adults. 5. Laskowski ER (expert opinion). Mayo Clinic, Rochester, Minn. 6. Heat stress-heat related illness. Centers for Disease Control and Prevention.

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Alcohol-Like Mouth Odor!? CAUTION! Sarah Amira O., Wisnu Satrio E. L., Ardhito Rahadian, M. T. Yuki Inzaghi From Faculty of Medicine, Universitas Kristen Indonesia Background This poster is dedicated to spread information and give awareness to public about one of emergency state of diabetes mellitus which is: Diabetic Ketoacidosis. Especially for people with type 1 diabetes. And most of times appeared as a first clinical manifestation of a diabetic patients who hasnâ&#x20AC;&#x2122;t been diagnosed yet. some conditions that can triggers diabetic ketoacidosis are infection, myocardial infarction, stroke, pancreatitis, trauma, and bad medication adherence. Itâ&#x20AC;&#x2122;s happens because of severe insulin deficiency that cause breakdown of fatty acids (lipolysis) that produces ketone bodies. Diabetic ketoacidosis (DKA) continues to have high rates of morbidity and mortality despite advances in the treatment of diabetes mellitus.

Diabetic

ketoacidosis (DKA) closely related to the quality of life of people with diabetes mellitus and therefore it is important to raise awareness to the public about DKA Keyword: Diabetes, alcohol-like mouth odor, sweet urine, acidosis

References: 1.

Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25 2. Lin SF, Lin JD, Huang YY. Diabetic ketoacidosis: comparisons of patient characteristics, clinical presentations and outcomes today and 20 years ago. Chang Gung Med J. 2005 Jan. 28(1):24-30.

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"ALCOHOL” LIKE MOUTH ODOR?

CAUTION !

DIABETIC KETOACIDOSIS IS A SERIOUS COMPLICATION OF DIABETES THAT OCCURS WHEN YOUR BODY PRODUCES HIGH LEVELS OF BLOOD ACIDS CALLED KETONES. THE CONDITION DEVELOPS WHEN YOUR BODY CAN'T PRODUCE ENOUGH INSULIN.

THE SIGN

THE SOLUTION

FREQUENT URINATION

INSULIN INJECTION

VOMITING

FLUID AND ELECTROLITE REPLACEMENT

EXTREME THIRST

FRUITY SMELLING BREATH

KNOW THE

DKA IS SERIOUS,

SIGN

BUT IT CAN BE PREVENTED.

KNOW THE

SOLUTION

YOUR TREATMENT PLAN AND BE PROACTIVE

ABOUT YOUR HEALTH. 331

TRIPLE C: FOR BURNS Airlangga University Saskia Intandivanty, Annisa Rahma, Isna Yefa, Qurrota Ayunin Background A burn is a trauma caused by heat, electric current, chemicals and lightning that affect the skin, mucosa and deeper tissues. Extensive burns affect metabolism and function every cell of the body, all systems can be disrupted, especially the cardiovascular system. Burns can be divided into first degree, second superficial, second deep, and third degree. First-degree burns only affect the epidermis accompanied by erythema and pain. Superficial seconddegree burns extend to epidermis and part of the dermis layer accompanied by blisters and very painful. The woundsecond degree burn in extends throughout the dermis. Third-degree burns extend to the epidermis, dermis, and subcutaneous tissue, often capillaries and veins charred and blood to the tissue is reduced (Corwin, 2000). Objectives (Aim) To inform the readers about burns and ways to do first aid in burns. Brief Research Methodology When we did brainstorming to make a public poster, we use the discussion method with basic literature from books and the internet to get information. Then, we established the division of tasks in making this poster. Key Findings Burns, cool, cover, call. Source Honniasih, M. 2011. Luka Bakar. Surakarta:UNS

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Management of Snakes Bite Satria Addienul Haq Fakultas Kedokteran Universitas Kristen Kirda Wacana

Abstract Indonesia was one of tropical countries in the world, and Indonesia have many things from culture, flora, and fauna. One of the important things for Indonesia is health care, in tropical countries we encounter a really special case that only happen in tropical countries which is tropical diseases. In Indonesia or other tropical countries have so many kind of snake species, that is why knowing how to treat snakes bite is important. Snake bites happen in most of rural area, which is the habitat of most snakes because rural area consist of big trees, paddy field, and other things. The most important thing to treat snake bites is time, you only have 30 minutes to get to hospital from the first time you got bite, only hospital have antivenom for snakes. First you need to calm down, if you the one who accompany the person who got bite, don’t leave him or her, clean up the wound, don’t wash it, and then bandage it tightly yet not too tight, don’t move it, don’t suck it, and go to hospital or nearest medical facilities that have snakes antivenom.

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The Other Side of Diarrhea Satria Angga Widitama, Kelly Yosefinata, Nitzia Annisa Fitri Padjadjaran University

Diarrhea is the second leading cause of death in children under five years old. The main causes of death from diarrhea is fluid loss and severe dehydration. Diarrhea makes electrolytes and water lost through vomit, urine, sweat, breathing, and liquid stools during a diarrhea episode. If the lost from the body are not replaced, dehydration occurs. According to Kemenkes RI, the prevalance of diarrhea in children under the age of five years old is 12.3%. Diarrhea can be caused by infection (bacteria, viral, parasitic organism), malnutrition, faecescontaminated water, poor hygiene and sanitation. In this case, the role of parents play important thing. Parents should know what is the signs of diarrhea complication (dehydration), how to prevent, and how to give proper treatment as soon as diarrhea begins. Nowadays, there are so many people still assume that diarrhea is not a serious issue. But the fact is diarrhea can be life-threatening. Recent studies has shown a lack of awareness of diarrhea among policy makers, health care practitioner, and the community in Indonesia. Therefore, we hope that parents can be more aware and be fast to give treatment, also policy makers, health care practitioner, and the community do not underestimate the life-threatening effect of diarrhea anymore.

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Brief Research Methodology We gathered information through guidelines from WHO, CDC, and data from Kemenkes RI 2018, analyzed and summarized the information to make them easily understood. Key findings: Etiology of diarrhea Epidemiology of diarrhea Sign of dehydration Treatment Prevention Sources: WHO â&#x20AC;&#x201C; Diarrhoeal Disease CDC (Centers for Disease Control and Prevention)

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STROKE? ACT FAST AND LIFE WILL LAST Universitas Pelita Harapan Sharon Chen, Rivaldo Steven Heriyanto, Billy Susanto, Dewa Ayu Kalista Liani Adiya Stroke is a disease that affects the arteries leading to and within the brain. It occurs when a blood vessel that carries oxygen and nutrients to the brain is either ruptured or blocked by a clot. When that happens, the brain can’t get enough blood and brain cells will die. With our stroke prevalence being 14,6 per 1000, Indonesia’s population of stroke is over 6 times the amount of Brunei’s and can make up as much as 60% of Singapore’s whole population. That being said, with this poster, we aim to bring this disease to light and educate citizens about how they can contribute by noticing the first signs of stroke. The objective of this poster is to raise public awareness about the first signs of stroke. Because stroke treatments that work best, such as thrombolytics, are only available if stroke is diagnosed within 3 hours of the first symptoms, it is crucial to recognize and diagnose stroke as fast as possible. With 90% of stroke cases being preventable within it’s golden period and with the right treatment, we aim to raise awareness on the first signs of stroke that will allow quick diagnosis so patients can get better treatment.

References 1. American

Stroke

Association.

About

Stroke.

(2019).

Retrieved

from

https://www.stroke.org/en/about-stroke 2. Centers for Disease Control and Prevention. Stroke: Signs and Symptoms (2018). Retrieved from https://www.cdc.gov/stroke/signs_symptoms.htm 3. Mesiano, T. (2017). Apa itu Strok? World Stroke Day 2017. Presentation.

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ACT FAST AND LIFE WILL LAST

GET TO KNOW THE FIRST SIGNS OF STROKE

ACE

Does one side of the face droop when the person smiles?

RMS

Does one arm drift downward when the person raises both hands?

PEECH

Is the person's speech slurred or strange?

If you see any of these signs,

IME

call emergency right away!

Stroke treatments are best when the stroke is recognized and diagnosed within 3 hours of the first symptoms.

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Save Life from Getting Electric Shock with SMACK Shisilia Mitra Novita, Saskia Rezky D. L., Laila Faiqotul Husna, Putri Brilian B.V. Faculty of Medicine Airlangga University ABSTRACT Background: Electric shock refers to the injury caused by the passage of electricity through the body. The most common causes are faulty or poorly maintained indoor electrical supplies. Our body is conductive with resistance varying depending on which part to measure and how electrical contact is made. Thus, electrical shock is an emergency situation. Based on latest study, electric shock is related to significant morbidity and mortality in children, adolescent, and adult. Electrical shock can cause severe burns, cardiopulmonary arrest, and other multisystem complications. Approximately, 300 deaths and 4000 injured people is caused by electrical shock. However, many people believe that normal household current and insulated power lines are not lethal and pose a hazard. This public poster is a recommended way to warn and educate them but still there is an obstacle to introduce our project to illiterate people. Hence, verbal introduction is needed. Objective: This project is designed to persuade people, knowing what to do in an electrical shock incident in order to save a life by SMACK, to prevent and minimize electric shock-caused morbidity and mortality by educating people. Brief Research Methodology: We conduct this public poster by journal article literation. Keyword: electric shock, emergency, first aid References: Boon, Elizabeth; Parr, Rebecca, 20.000 Danda, Samarawickrama (2012). Oxford Handbook of Nursing Dental . Oxford University Press. Page 132. ISBN 0191629863. Roberts, S., & Meltzer, J. A. (2013). An evidence-based approach to electrical injuries in children. Pediatric emergency medicine practice, 10(9), 1-16. Kumar, S., Verma, A. K., & Singh, U. S. (2014). Electrocution-related mortality in northern Indiaâ&#x20AC;&#x201C;A 5year retrospective study. Egyptian Journal of Forensic Sciences, 4(1), 1-6. https://www.entergynewsroom.com/media-kit/electric-safety-how-shock-happens/ accesed October 1đ?&#x2018; đ?&#x2018;Ą 2019 at 18:17.

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Seizure, Make Sure Youâ&#x20AC;&#x2122;re Not Insecure Jenderal Achmad Yani University Tazkiya Qalby, Tsana Makarim, Shela Azizah, Selvia Epilepsy, in Greek, Epilambanmein has a meaning as an attack. Before, people believed that epilepsy was a sacred disease caused by evil spirits. In fact, epilepsy is a manifestation of impaired brain function with various etiologies with the typical single symptom that is recurrent seizures due to local electrical sparks on the brain's substantia grisea that occur at any time, sudden, and very fast which can result in decreased consciousness, changes in motor function or sensory, behavioral or emotional intermittent and stereotypic. Epilepsy affects about 50 millions people throughout the world common in childhood and in elderly people. Status epilepticus (SE) is a neurological emergency, can cause brain damage and even death if left untreated. Based on the recent understanding of the pathophysiology, SE is defined as a continuous seizure that lasts more than 5 min probably needs to be treated as SE. SE mortality in hospitals increases gradually with age and SE severity. The prognosis of patients with epilepticus status is related to the etiology, duration of epilepticus status, and the patient's age. Epilepsy is disabling neurologic condicition, so the awareness of people must be increased to prevent a worse condition of epilepsy. Keywords : Seizure, Awareness, Status Epilepticus.

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Cardiogenic Pulmonary Edema: Every Breath Counts Thania Lathifatunnisa Putri Agusti, Shalsabila Refithania Yanata, Tsamara Nurwina Nugroho Faculty of Medicine, Diponegoro University Corresponding e-mail: thania.lpa@student.undip.ac.id, shalsabilaryanata@students.undip.ac.id, winanugroho@students.undip.ac.id

ABSTRACT Aim The unavailability of medical professionals on premise of CPE (Cardiogenic Pulmonary Edema) emergency might put the patient in higher risk. In this situation, there are three things to consider: 1.

Correct posture of the patient to allow proper airway and breathing.

Clearance for the patientâ&#x20AC;&#x2122;s air circulation through:

Bringing the patient to open surroundings

Unclothing the patientâ&#x20AC;&#x2122;s clothes that might restrict air circulation

Comfort of the patient.

Any underlying cause should be identified when starting treatment.

Background/Introduction Pulmonary edema is a life-threatening condition with an estimated 75.000 to 83.000 cases per 100.000 persons having heart failure and low ejection fraction. It refers to the accumulation of excessive fluid in the alveolar walls and spaces of the lungs which can be (1) Cardiogenic (disturbed starling forces involving the pulmonary vasculature and interstitium) or (2) Non-Cardiogenic (direct injury/damage to lung parenchyma/vasculature). Brief Research Methodology The method used in this research is systematic literature review by planning, conducting, and planning about Cardiogenic Pulmonary Edema. We also use advance research with PubMed Central as the main database.

Key Findings Cardiogenic Pulmonary Edema, Emergency, Management

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References: 1. Nendrastuti, H. et al. (2010) ‘Edema Paru Akut Kardiogenik Dan Non Kardiogenik’, Majalah Kedokteran Respirasi, 1(3), p. 2010. Available at: http://journal.unair.ac.id/download-fullpapersMKR Vol1 No 3 - 2 Abs.pdf. 2. Purvey, M. and Allen, G. (2017) ‘Managing acute pulmonary oedema’, Australian Prescriber, 40(2), pp. 59–63. doi: 10.18773/austprescr.2017.013.

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ABSTRACT How to PASS Shortness of Breath Aurelia Gendis, Chatrine Angelica D. C., Joyna Getruida S., Timothy V. P. Reba From Faculty of Medicine, Universitas Kristen Indonesia Background Dyspnea or shortness of breath is a condition where a person has difficulty breathing. These symptoms can affect millions of people where the sensation and intensity can be different and occur subjectively1. Dyspnea or shortness of breath that occurs suddenly becomes one of the challenges in handling it in the emergency department2. Dyspnea can be caused by many different underlying factors, some of which arise acutely and can be life-threatening and it is a common symptom affecting as many as 25% of patients seen in the ambulatory setting3. To deal with shortness of breath which is now an emergency and requires direct treatment, we have four methods that are summarized in PASS. P

- Pain medicines to relieving pain in the chest

A - Antianxiety medicines to help break the panic S

- Steroids to help reduce swelling in the lungs

- Sitting and relax your body for breathing easier

Objective To introduce creative ways to overcome the problem of shortness of breath to the public. Keywords Dyspnea, Emergency medicine References 1. Sharma S, Hashmi M, Badireddy M. Dyspnea on Exertion (DOE). StatPearls [Internet]. 2019 September 12 [cited 2019 September 26]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499847/ 2. Guttikonda S, Vadapalli K. Approach to undifferentiated dyspnea in emergency departments: aids in rapid clinical decision-making. Int J Emerg Med [Internet]. 2018 April 4; 11-21 [cited 2019 September 26]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5884754/#CR1

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3. Berliner D, Schneider N, Welte T, Bauersachs J. The Differential Diagnosis of Dyspnea. Dtsch Arztebl Int [Internet]. 2016 Dec 6; 113 (49): 834â&#x20AC;&#x201C;845. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5247680/

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Watch Your Drugs, As It can Leads to Severe Allergy Tithasiri Audi Rahardjo, Vania Verina Himawan, Zefania Regina Ardiani Faculty of Medicine, Diponegoro University Corresponding e-mail: tithasiriaudi@gmail.com, vania.v.himawan@gmail.com, zefaniareginard@gmail.com

ABSTRACT Aim: To increase awareness of Steven-Johnson Syndrome/Toxic Epidermal Necrolysis. Background: Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are the most worrisome drug eruptions seen in the emergency department, involving extensive epidermal necrosis and detachment, with mucocutaneous complications. 12 This condition mostly caused by medication, such as allopurinol, anticonvulsants, and antibiotics.3 SJS and TEN differ only along a spectrum of severity based on percentage of body surface involvement (<10% in SJS, 10%-30% in SJS/TEN overlap, 30% in TEN).2 The incidence of SJS is approximately 5 cases per million people per year, and whereas TEN is approximately 2 cases per million people per year. 4 SJS/TEN may lead to massive fluid and protein loss, electrolyte imbalances, evaporative heat loss with subsequent hypothermia, and hypovolemia.2 It is surely a life-threatening state. Immediate recognition and initial treatment must be performed to reduce mortality.4 Method: We collected Journal related to topic. The inclusion criteria are those published during 20152019. Key Findings: Steven-Johnson Syndrome, Toxic Epidermal Necrolysis, drug eruption, emergency.

References 1.

Dharamsi FM, Michener MD, Dharamsi JW. Clinical Communicationâ&#x20AC;Ż: Adults Bullous Fixed Drug Eruption Masquerading As Recurrent Stevens. J Emerg Med. 2014;(September):1-4. doi:10.1016/j.jemermed.2014.09.049.

Stephen Alerhand, MD, Courtney Cassella, MD, and Alex Koyfman M. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in the Pediatric Population A Review. 2016;32(7):472-478.

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Chantaphakul H, Sanon T, Klaewsongkram J. Clinical characteristics and treatment outcome of Stevens-Johnson syndrome and toxic epidermal necrolysis. Exp Ther Med. 2015:519-524. doi:10.3892/etm.2015.2549.

Oki Suwarsa, Wulan Yuwita, Hartati Purbo Dharmadji and ES. Stevens-Johnson syndrome and toxic epidermal necrolysis in Dr. Hasan Sadikin General Hospital Bandung, Indonesia from 2009â&#x20AC;&#x201C;2013. Asia Pac Allergy. 2016;(6):43-47.

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watch your D R U G S ! ..as it can leads to severe allergy

red

be aware, safe a life 353

WHAT TO DO WHEN THE WORLD SHAKES?

VINDY VANESSA WENNAS 011911133096 ALYA KUSUMANINGRUM 011911133102 DIVA SAPHIRA 011911133092 POPPY AZURA PUTRI 011911133093

FACULTY OF MEDICINE UNIVERSITAS AIRLANGGA

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ABSTRACT WE NEED YOU (ALIVE)! William Wiradinata1, Ni Made Susanti1, Luh Elda Geraldine1, Putu Ijiya Danta1 1

Medical Faculty of Brawijaya University

Background : Cardiac arrest is the abrupt loss of heart function in a person who may or may not have been diagnosed with heart disease. It can come on suddenly, or followed by other symptoms. Cardiac arrest caused by irregular heart rhythms, called arrhythmias. A common arrhythmia associated with cardiac arrest is ventricular fibrillation which the heart’s lower chambers suddenly start beating chaotically and don’t pump blood or called “arrest”. Cardiac arrest is still a major international public health problem estimated 15%–20% of all deaths. About 350,000 cardiac arrests happen outside of hospitals each year—and about 7 in 10 of those happen at home. In 2017, The American Heart Association (AHA) develops science-based CPR guidelines. Cardiopulmonary Resuscitation (CPR) is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac

arrest.

As cardiac arrest often occurs in unexpected places around us, everyone must understand and able to do the emergency management of Cardiac Arrest. Objective : To inform people how to recognize people with cardiac arrest and early management of cardiac arrest because WE NEED YOU to have a role in giving people chances of being ALIVE. References : American

Heart

Association.

(2017,

March

31).

Cardiac

Arrest.

Retrieved

from

https://www.heart.org/en/health-topics/cardiac-arrest Kleinman, M. E., Goldberger, Z. D., Rea, T., Swor, R. A., Bobrow, B. J., Brennan, E. E., ... & Travers, A. H. (2018). 2017 American Heart Association focused update on adult basic life support and cardiopulmonary resuscitation quality: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 137(1), e7-e13. Hayashi, M., Shimizu, W., & Albert, C. M. (2015). The spectrum of epidemiology underlying sudden cardiac death. Circulation research, 116(12), 1887-1906.

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PREVENT SUICIDE WITH SHINE Wiranigitasari, Ave Maria, Nanda Ayu Shabrina, Shafa Maulida AMSA-Universitas Brawijaya

BACKGROUND Suicide is a leading cause of death in adolescents, and is one of the most common psychiatric presentation of the youth to the Emergency Department. According to World Health Organization, every year, almost 800,000 people take their own life and 20 million attempt to do the same thing. Suicide is a serious public health problem and it usually started from an ideation of suicide. A study conducted in Japan in 2015 shows that the progression from the onset of suicide ideation until the suicide attempt mostly occurs in only one day. In suicide prevention, strategies can be directed toward health care services or at the general population. This marks surroundings play an important role to prevent the attempt happens. However, suicides are preventable with timely, evidence-based and often low-cost interventions. OBJECTIVES To inform people what should they do when they see someone who has a tendency to commit a suicide action and to decrease the number of people die by suicide.

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PREVENT SUICIDE WITH

B E C AU S E A SECOND COULD S AV E A LIFE

Every year, close to

800,000 people die by suicide with one person die

every 40 seconds

Stay by the person side

H Hit emergency number

Invite the person to talk with you 360

Eliminate

judging

dangerous

and patronizing

thing from the person

Beware of Eclampsia: Treat with ‘TIC TAC’ Yosia Yonggara, Vincent Kurniawan, Benedictus, Shohifa Dzauqiah S Faculty of Medicine, Sebelas Maret University Abstract Pre-eclampsia is a systemic syndrome of hypertension and proteinuria in pregnancy (Gupte, 2014). Meanwhile, eclampsia is a tonic-clonic seizure manifested in pre-eclampsia women (Gill, 2019). These diseases are the major cause of fetal and maternal mortality (Ayoubi, 2011). 3-5% of all pregnant women affected by these diseases and cause more than 60.000 maternal and 500.000 fetal death per year worldwide (Peres, 2018). Eclampsia is a serious disorder that needs special attention because of the multi-organ system that can be affected. The patient that had experienced eclampsia has to be monitored because of the serious complications that may occur, which are cortical blindness, neurological deficits, stroke coronary event, renal failure, liver dysfunction, DIC, death, and intrauterine growth restriction (Gill, 2019). Signs that can be seen before eclampsia include persistent frontal or occipital headache, blurred vision, photophobia, right upper quadrant or epigastric pain, and altered mental status. The fact shown above proves that these are a life-threatening disease. Unfortunately, the knowledge of the public toward the disease is still limited (Akeju, 2016; Savage, 2016; Wilkinson, 2017). Thus, through this public poster, we aim to educate society about pre-eclampsia and eclampsia, its danger, and first-aid. To help the society remembering the first-aid of eclampsia, we proposed a tagline “TIC TAC” which is an acronym for the instructions in an emergency Keyword: Pre-eclampsia, Eclampsia, First-aid References: Akeju, D. O., Vidler, M., Oladapo, O. T., Sawchuck, D., Qureshi, R., … Dada, O. A. (2016). Community perceptions of pre-eclampsia and eclampsia in Ogun State, Nigeria: a qualitative study. Reproductive Health, 13(S1). doi:10.1186/s12978-016-0134-z Ayoubi. (2011). Pre-eclampsia: pathophysiology, diagnosis, and management. Vascular Health and Risk Management, 467. doi:10.2147/vhrm.s20181 Gill, Prabhcharan., Tamirsa, Anita P., And Hook, James W. Van. (2019). Acute Eclampsia. Treasure Island (FL):StatPearls Publishing Gupte, S., & Wagh, G. (2014). Preeclampsia–Eclampsia. The Journal of Obstetrics and Gynecology of India, 64(1), 4–13. doi:10.1007/s13224-014-0502-y Peres, G., Mariana, M., & Cairrão, E. (2018). Pre-Eclampsia and Eclampsia: An Update on the Pharmacological Treatment Applied in Portugal. Journal of Cardiovascular Development and Disease, 5(1), 3. doi:10.3390/jcdd5010003 Savage, A. R., & Hoho, L. (2016). Knowledge of pre-eclampsia in women living in Makole Ward, Dodoma, Tanzania. African Health Sciences, 16(2), 412. doi:10.4314/ahs.v16i2.9 Wilkinson, J., & Cole, G. (2017). Preeclampsia knowledge among women in Utah. Hypertension in Pregnancy, 37(1), 18–24. doi:10.1080/10641955.2017.1397691

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AMINO | PCC EAMSC 2020: INDIA

ABSTRACT Title: Surgical Site Infection of Open Fracture Grade IIIC Caused by Biofilm-Producing MethicillinResistant Staphylococcus aureus (MRSA) in RSD dr. Soebandi Jember Authors: Yehuda Tri Nugroho Supranoto1 , Ali Habibi1 , Siti Zulaikha1 , Rahadinda Mutia1, I Nyoman Semita2, Dini Agustina3, Yudha Anantha Khaerul Putra4 1

Faculty of Medicine Universitas Jember, Jember, Jawa Timur, Indonesia

Department of Orthopaedic Rumah Sakit Daerah dr. Soebandi, Jember, Jawa Timur, Indonesia

Department of Microbiology, Medical Faculty Universitas Jember, Jember, Jawa Timur, Indonesia

Department of Emergency Medicine, Rumah Sakit Daerah dr. Soebandi, Jember, Jawa Timur, Indonesia

AMSA-Indonesia A 60-year-old male presented to the Emergency Department of Rumah Sakit Daerah (RSD) dr. Soebandi Jember with a severe open fracture of his right lower extremity especially right leg (cruris dextra) after hit by a truck in a traffic accident. Patient came with massive bleeding because the rupture of tibial and femoral arteries. His current blood pressure at that time was 90/60 mmHg. So, it was suspected as hypovolemic shock since his Capillary Refill Time (CRT) is delayed more than 2 seconds and his lower extremity lacks of perfusion. He had already given initial prophylactic antibiotic treatment such as cefazolin and amoxicillin. After more than 3 months, he suffered a pyogenic infection with a biofilm plaque formation on his surgical sites. The diagnosis of surgical site infection (SSI) by Methicillinresistant Staphylococcus aureus (MRSA) was made after passing microbiology identification and antibiotic susceptibility test using Kirby Bauer disc diffusion methods. This S.aureus resisted to 12 of 18 antibiotics that was tested including beta-lactams and macrolides groups of antibiotics. This case report of surgical site infection in a postoperative of severe open fracture can be used to evaluate the empirical treatment and the proper use of antibiotics that is used in emergency department of RSD dr. Soebandi. This report is an initial step to do some studies in order to conclude the evidence of nosocomial infection in emergency department of RSD dr. Soebandi. Hospitalâ&#x20AC;&#x2122;s Antibiogram is needed for having a high efficacy of nosocomial infection treatment. Future research should aim to identify and quantify the incidence risk of infection after treatment by the hospital. Moreover, it also should aim to conclude the best practices for management of infection and for prophylactic antibiotic use.

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A Case Report: Surgical Site Infection of Open Fracture Grade IIIC Caused by Biofilm-Producing Methicillin-Resistant Staphylococcus aureus (MRSA) in RSD dr. Soebandi Jember East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2020

Presented by Yehuda Tri Nugroho Supranoto Ali Habibi Siti Zulaikha Risqiyani Rahadinda Mutia Supervised by dr. I Nyoman Semita Sp.OT (K) Spine dr. Dini Agustina, M. Biomed dr. Yudha Anantha Khaerul Putra

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A Case Report: Surgical Site Infection of Open Fracture Grade IIIC Caused by BiofilmProducing Methicillin-Resistant Staphylococcus aureus (MRSA) in RSD dr. Soebandi Jember Yehuda Tri Nugroho Supranoto1, Ali Habibi1, Siti Zulaikha1, Rahadinda Mutia1, I Nyoman Semita2, Dini Agustina3,Yudha Anantha Khaerul Putra4 1 Faculty of Medicine Universitas Jember, Jember, Jawa Timur, Indonesia 2 Department of Orthopaedic Rumah Sakit Daerah dr. Soebandi, Jember, Jawa Timur, Indonesia 3 Department of Microbiology, Faculty of Medicine Universitas Jember, Jember, Jawa Timur, Indonesia 4 Department of Emergency Rumah Sakit Daerah dr. Soebandi, Jember, Indonesia Instead of that, loss of skin integrity and exposure of

INTRODUCTION

the subcutaneous tissue provides a warm, conducive

Open fractures are complex injuries involving the

environment for the colonization and growth of

bones and surrounding tissue (Gupta et al., 2012).

microorganisms unless it is treated with prophylactic

According to the 2017 American Academy of

antibiotics and surgical debridement. The management

Orthopedic Surgeons (AAOS), open fractures are

of open fracture cases is different from closed fracture

broken bones with open wounds and skin damage

cases because there are indications of complications of

caused by bone fragments that penetrate the skin at the

bone and tissue infections around post-surgical sites.

time of injury (AAOS, 2017). Open fracture has

The goals of open fractures management include the

already classified by Gustilo and Anderson based on

prevention of infection, achievement of bone union,

wound size, level of contamination, and osseous injury

and the restoration of function. Once infection is

as follows: Type I is an open fracture with a wound

established, wound healing is delayed, treatment cost

less than 1 cm long and clean; Type II is an open

rises, and the wound management practises become

fracture with a laceration more than 1 cm long without

more difficult (Azar F, 2012). Based on World Health

extensive soft tissue damage; and Type III is an open

Organization (WHO) data in 2016, Surgical Site

fractures that are segmented with an extensive damage

Infections (SSIs) occur in 11% of patients undergoing

of soft tissue and vascular (Kim & Leopold, 2012).

the procedure operations in developing countries

Type III of Open Fracture also divided to 3 subclasses

(WHO, 2016).

with the most severe is type C because it is associated

SSIs associated with external or internal

with arterial injury and massive contamination (Ghoshal et al., 2010). Some of open fracture cases

fixation

need an operative fixation. The operative fixation of

complications. Septicemia followed by shock can be a

skeletal fractures can be highly complex due to the

serious emergency case for this complication. Based

unpredictable nature of the bone damage. One of the

on the previous research by Oliveira in the Instituto de

most challenging complications in this management is

Ortopedia e Traumatologia, the primary infectious

Infection after fracture fixation (IAFF) (Metsemakers

agents isolated from the SSI is Staphylococcus aureus.

et al., 2018). By breaking the skin, an open fractures

Because of that, basically, the prophylaxis antibiotics

eliminate one of the major barriers to infection.

that can be prescribed to the patient is usually beta-

Bacterial contamination has been shown to occur in

lactam

upto 70% of open fracture wounds (Gupta et al., 2012).

accordance to that, patients with open fracture who

367

fractures

including

are

regarded

cephalosporin

serious

category.

underwent surgery for fixation of their fractures

most hospitals as Hospital Associated MRSA. National

received Cefazolin empirically (Oliveira et al., 2016).

Nosocomial Infection Surveillance (NNIS) System

To make it clear, diagnostic microbiology plays a

data demonstrate a steady increase in the incidence of

crucial role in the control of infection to prevent severe

nosocomial infections caused by MRSA among ICU

complication

patients over time. MRSA now accounts for>60% of

such

emergency

septic

shock

Staphylococcus aureus isolates in United States

(Mangala et al., 2018).

hospital ICUs. In surgical site infection, MRSA

Overall, Staphylococcus aureus was the

occurred in 27 of 9,863 cases (0.27%) (Msed et al.,

commonest bacteria isolated of the cultures in the

2012). This indicates that this case is quite rare.

postoperative period. The higher rate of isolation of

Resistance

Staphylococcus aureus in the postoperative period may

penicillin

specifically

be due to the production of several virulence factors

methicillin is encoded and regulated by a sequence of

and also the property to forms biofilms adhering to the

genes found in a region of the staphylococcal cassette

wound (Mangala et al., 2018). Sometimes, resistancy

chromosome mec (SCCmec). This mecA gene encode

can be caused of quorum sensing mechanism in the

a low affinity penicillin binding protein (PBP2a) that is

biofilm.

responsible for the resistance. They can alter their cell Bacterial

biofilms

are

communities

walls especially their peptidoglycan so that it can resist

all the pencillin and cephalosporin groups.

microorganisms that are attached to an underlying foreign body or tissue substrate and held together by a

There is currently a development of resistancy

self-produce dextra cellular matrix. Bacteria that can

in Staphylococcus aureus that is different from MRSA.

form biofilms are Escherichia coli, Pseudomonas

Vancomycin-intermediate

aeruginosa, Bacillus subtilis, Staphylococcus aureus,

(VISA) and Vancomycin-resistant Staphylococcus

and many more. Inside the host, biofilms allow

aureus (VRSA) can generally isolated from patient

pathogens to inhibit innate immune defenses and are

with complex infection who have prolonged treatment

thus associated with long-term persistence (Kostakioti

of vancomycin. VRSA also can be developed by

et al., 2014).

acquiring VanA gene that is derived from enterococci. (Carrol et al., 2016).

non-motile, pus-producing coccus. Microscopically, S

CASE HISTORY AND EXAMINATION

aureus has the appearance of 0.5- to 1.5-Âľm ballsthat are clumped together, like grapes. Methicillin was

A 60-year-old male presented to the Emergency

introduced as an antibiotic against Staphylococcus

Department of Rumah Sakit Daerah Soebandi Jember

aureus in 1959. In 1961, Staphylococcus aureus had

at 4.08 p.m on 23rd May 2019 with a severe open

begun developing resistance to methicillin and quickly world

wide.

Now,

fracture of his right lower extremity especially right

Methicillin-resistant

leg (cruris dextra). His mode of injury was a traffic

Staphylococcus aureus (MRSA) may be resistant to

accident. He was hit by a truck on the onset of time

penicillin and cephalosporin antibiotics, and more than

was around 8.00 a.m. As itâ&#x20AC;&#x2122;s shown on Figure 1,

50% are resistant to antibiotic such as macrolides,

patient came with massive bleeding because the

lincosamides, fluoroquinolones, and aminoglycosides; and

30%

are

resistant

aureus

VanA gene responsible for resistancy to vancomycin

Staphylococcus aureus is a Gram-positive,

spread

Staphylococcus

rupture of tibial and femoral arteries. His current blood

trimethoprim-

pressure at that time is 90/60 mmHg. It was suspected

sulfamethoxazole. Now, its considered endemic to

as hypovolemic shock since his Capillary Refill Time 368

was delayed more than 2 seconds and his lower

BUN

15 mg/dL

2-20 mg/dL

extremity lacked of perfusion.

Blood Glucose

101 mg/dL

79-140 mg/dL

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen

After the operative procedure, patient needed to stay at hospital for around 1 week to have a prophylaxis antibiotics and stabilization of his general condition. The antibiotic that applied to this patient was cefazolin 0.5-1 g/8 hours until 24 hours. Outpatient medication for preventing the Surgical Site Infection of this case was Amoxicillin 500 mg/8 hours. Unfortunately, this Hospital doesnâ&#x20AC;&#x2122;t have a strict guideline of antibiotics prophylaxis for preventing the SSIs.

Figure 1. Pre operative condition The

operative

procedure

initiated

anesthesia with subarachnoid block method using the combination of Midazolam 1 mg, Fentanyl 25 mg, Ketamin 10 mg, and Marcain 10 mg. Because of the segmented fracture with soft tissue and vascular damage, open reduction and external fixation (OREF) method was needed. But, before the operative Figure 2. Radiography of lower leg fractures

procedure, patient needed to have laboratory test to ensure the general condition of the patient is ready.

After more than 3 months, patientâ&#x20AC;&#x2122;s surgical

The results of blood examination are shown below in

site develop pyogenic wounds. Uniquely, the wound

the Table 1.

produced thin white membrane that covers several parts. It is suspected as a biofilm since the definition of

Table 1. Laboratory test result

biofilm is an assemblage of microbial cells that is

Value Laboratory test Hb White blood cells Hematocrit

Pre-

Post-

Normal

Operative

Range

7.6 g/dL

7.3 g/dL

22.2k/mcL 23.4 %

be formed since he had a severe and life threatening

g/dL

open fracture before. SSIs can be caused by bacteria

12.4k/mcL

4-11 k/mcL

resistancy or bad hygenity environment. Those

21.2 %

45% 52%

194k/mcL

128k/mcL

AST

15 units/L

ALT creatinine

matrix. Biofilm formation and infection can possibly

13.5-17.5

Platelets

Serum

enclosed in an extracellular polymeric substance

resistancy can be made by initial mistreatment of prophylaxis antibiotics. Our initial hypothesis was that

150400k/mcL

there was resistance to amoxicillin and cefazoline

9-36 units/L

given as initial treatment for this patient since he

11 units/L

5-40 units/L

admited not having a history of hypertension, diabetes,

1.3 mg/dL

0.5-1.5 mg/dL

and other severe chronic diseases.

369

immediately after the sample arrived at Microbiology Department of Medical Faculty of Universitas Jember. This inoculation must be done immediately after the wound swab. The results of that wound culture were identified biochemically and microscopically. The bacterial colony was cocci and was Gram-positive. Based on that staining, it was suspected as staphylococci or streptococci. The catalase and coagulase test results were positive. Catalase test was done to make sure that the pathogen is staphylococci. While, coagulase test for ensuring that pathogen is Staphylococcus aureus. The bacterial culture results

Figure 2. White pyogenic plaques on surgical site (after 3 months of surgery and fixed with OREF method) suspected as bacterial biofilm infection. MICROBIOLOGY

EXAMINATION

were replanted on Mannitol Salt Agar (MSA) media. The results showed that bacteria could grow on MSA

AND

media and were able to ferment mannitol so that the

DIAGNOSIS

environment around the colony turned yellowish.

Because of having pyogenic white plaques wounds,

test

the

microbial

susceptibility

this patient was suspected to have a biofilm-producing

antibiotics, we used Kirby Bauer disc diffusion method

multidrug-resistant bacteria. The white plaques are

using Mueller Hinton Agar. Based on the research that

shown on the Figure 3. Pus was taken away with a

has already done by Oliveira in 2016, the most primary

sterile transport media and sealed inside an icebox to

causative agent in SSI cases is Community Acquired

maintain the mutual condition of the bacteria. Bacteria

Methicillin-resistant

inoculation using Blood Agar Plate (BAP) was done

MRSA). The antibiotic discs that was used to test out

Staphylococcus

aureus

(CA-

this sample were Penicillin 10 μg, Meropenem 10 μg, Ampisilin-Sulbactam 20 μg, Gentamicin 10 μg, Amoxicillin 25 μg, Amoxiclav 25 μg, Ciprofloxacin 5 μg,

Levofloxacin

μg,

Cefriaxone

μg,

Erythromycin 15 μg, Clindamycin 10 μg, Cefixime 5 μg, Cotrimoxazole 25 μg, Cefazolin 30 μg, Amikacin 30 μg, Cefepime 30 μg, Cefotaxim 30 μg, and Vancomycin 30 μg. All of this antibiotic disc were used to detect whether this Staphylococcus aureus is classified as MRSA or VRSA. Another reason is that those antibiotics are often used in RSD dr. Soebandi Jember, Jawa Timur, Indonesia. The

antibiotics

sensitivity can be quantify by measuring the diameter of inhibition of antibiotic disc and matching it to the

Figure 4. Bacterial Identification with Gram staining, Catalase test, and inoculation to Mannitol Salt Agar. The result was Staphylococcus aureus because it showed Gram-poisitve cocci with catalase positive and ferment mannitol.

standard from Clinical Laboratory Standard Institute (CLSI).

370

Figure 5. Antibiotic susceptibility test using Disc Diffusion method on Mueller Hinton Agar. It showed Resistancy on most Beta-lactam including Penicillins and Cephalosporin class.

Figure 6. Diagnostic of Vancomycin Resistant Staphylococcus aureus. It is showed that this organism suspected to resist the Vancomycin since its inhibitor zone under 15 mm.

371

Table 2. Antibiotic Susceptibility Test Results of Staphylococcus aureus based on Clinical Laboratory Standard Institute (CLSI) *VRSA can not be diagnosed only by Disc Diffsion method, it needs further test to ensure the minimum inhibotry concentration of

Antibiotic List

Content

CLSI Standard Diameter of Inhibitory

Diameter of

Conclusion

(μg)

Zone (mm)

Inhibitory Zone

(R/I/S)

Resistant

Intermediate

Susceptible

Sample (mm)

Penicillin

≤28

≥29

Meropenem

≤15

16-18

≥19

Gentamicin

≤12

13-14

≥15

Ciprofloxacin

≤15

16-20

≥21

Levofloxacin

≤15

16-18

≥19

Ceftriaxone

≤13

14-20

≥21

Amoxicillin

≤19

≥20

Ampisillin-

≤11

12-14

≥15

Erythromycin

≤13

14-22

≥23

Amoxiclav

≤19

≥20

Clindamycin

≤14

15-20

≥21

Cefixime

≤15

16-18

≥19

Cotrimoxazole

≤10

11-15

≥16

Cefazolin

≤14

15-17

≥18

Amikacin

≤14

15-16

≥17

Cefepime

≤14

15-17

≥18

Cefotaxime

≤14

15-22

≥23

Vancomycin

Sulbactam

Vancomycin. Though, based on CDC Algorithm for diagnostic VRSA, this can be concluded as suspected VISA/VRSA since VA zone <15 mm. VRSA can be diagnosed by disc dilution method only if VA inhibitory zone is 0 mm.

TREATMENT AND COURSE

CHALLENGES FACED

This case has already reported to the hospital and the

In developing countries like Indonesia, access to

patient already has endeavored a proper treatment and

hospitals is quite difficult for some people with low

control based on the microbiology examination result.

finance status. Unfortunately, complex infections like

For the treatment, patient was given Gentamicin

this often happen to them. In addition, hospitals and

topically and Clindamycin orally. The patient and his

health workers haven’t been able to reach and

family also have been educated well about this

guarantee the health of all citizens in this country. In

condition and what they need to do after especially

fact, to educate all the citizens about health program,

about personal hygiene and wound care that should be

they are still having trouble because there are too many

done by medical personnel. The patient has also been

citizens in Indonesia.

told that he must obey the control program schedule to

The selection of initial optimum treatment of

the hospital for evaluation and physiotherapy, so the

severe open fracture also one of the challenges of this

doctor can control the healing progress of patient’s

case. There is a consensus that the initial treatment of

wound.

these fractures should ideally be held in less than 6

372

hours. The initial mistreatment of open fracture really

condition included mostly on that criterias because of

becomes the high risk of SSIs.

his age, location of injury cleanliness, and high-energy injury since his mode of injury is hit by a truck in a

DISCUSSION

traffic accident. It is impossible to avoid the

Symptoms of SSIs included purulent drainage, wound

occurrence of SSI, as almost all of the identified risk

healing disturbance, erythema, and local pain (Doshi et

factors were not alterable. Therefore, the injury

al., 2017). Besides of that symptoms, there are three

characteristics, patient lifestyle habits, comorbidities,

main clinical presentations to diagnose surgical site

and

infection based on previous studies by Bonnvialle in

comprehensively and carefully evaluated to aid

2016:

instratifying the patients according to SSI risk and

suggestive, is the least common presentation; and/or

unwanted

results

should

measures (Sun et al., 2018).

surgical site with a fever, although strongly disorders

laboratory

enable the implementation of appropriate preventive

1. A purulent discharge from the incision and/or

2. Healing

preoperative

The white pyogenic plaques on the patient’s

and

wounds can be suspected as biofilm-producing

unusual local symptoms (local or regional pain

bacteria. But uniquely, this patient does not have most

or joint stiffness) are less obvious signs of

of the risk factors for biofilm formation based on the

infection;

anamnesis and physical examination. He is always

3. Absence of radiological evidence of bone

treated by medical personnel. He has no history of

healing after a few months, with or without

hypertension and diabetes. He also doesn’t use

incipient fixation failure, may also indicate

antibiotics carelessly and always obeys doctor’s

infection

prescription. He lives in a not bad environment, tropical and temperature. There was only one major

Based on the anamnesis, this patient has all this

risk factor of biofilm formation that he had, that is

symptoms eventhough it is already more than 3

initial mistreatment of antibiotic prophylaxis.

months since he went out from to the hospital to take an outpatient treatment. It appeared that the fractures

The microbiology test result was shown that

most impacted by contamination were the severe type

this patient suffer an surgical site infection caused by

III injuries (Zhu, Li, & Zheng, 2017).

Methicillin-resistant Staphylococcus aureus (MRSA). We defined it as Staphylococcus aureus since it was

Treatment of compound fractures has been the

positive in catalase test and coagulation test.

subject of controversy. In hospitals treating patients

Staphylococci

suffering from trauma, there is consensus that the

produce catalase,

which converts

hydrogen peroxide into water and oxygen. The

initial treatment of these fractures should ideally be

catalase test differentiates the staphylococci, which are

held in less than 6 hours. The initial mistreatment of

positive, from the streptococci, which are negative.

fracture really becomes the risk factor of surgical site

Staphyloccous aureus also produces an extracellular

infection (Fernandes M, et al.2015). Instead of that, the

coagulase, an enzyme like protein that clots oxalated

significant risk factors or predictors for SSI occurrence

or citrated plasma. Coagulase binds to prothrombin

were open injury, older age, incision cleanliness, high

and together they become enzymatically active and

energy injury, greater BMI, chronic heart disease,

initiate fibrin polymerization. Coagulase may deposit

history of allergy and area of injury that is mostly on

fibrin on the surface of staphylococci. To more

tibia fracture (Sun et al., 2018.). This patient’s

specify, our Staphylococcus aureus sample were 373

cultured on a specific media which is Mannitol Salt

algorithm is established for the management of soft

Agar (MSA) (Riedel S, et al., 2013).

tissue and fracture morphology while avoiding unnecessary overuse.

Antibiotics susceptibility test was done by

ACKNOWLEDGEMENTS

Kirby Bauer dilution method using 18 types of antibiotics disc. Based on Clinical Laboratory Standard

We express our sincere thanks to all of Physicians of

Institute (CLSI), this Staphylococcus aureus is

Emergency Department and Orthopaedic Department

resistant to Penicillin, Meropenem, Ceftriaxone, Amoxicillin,

Ampisillin-Sulbactam,

specialist in RSD dr. Soebandi Jember for their

Erythromycin,

cooperation of evaluating the patient’s treatment so

Amoxiclav, Cefixim, Cotrimoxazole, Cefazonline,

far. We also express our thanks to Medical Faculty

Cefepime, and Cefotaxime. It means that this

Universitas

Staphylococcus aureus can resist antibiotics of the

Jember

especially

for

Microbiology

Department and our vice dean of student affairs for

group of beta-lactams, cephalosporins, and also

giving permission and full support to conduct research

macrolides. Moreover, it can resist the Amoxicillin-

to this case.

Clavulanic acid. Clavulanic acid is an additional ingredient to inhibits beta-lactamases enzyme. By this

REFERENCES

condition, this antibiotic still not effective in this case.

Azar

For this case we can conclude that all the antibiotic

Beaty

Campbell

Canale

(2012).Campbell's Operative orthopaedics.

treatment including the prophylactic treatment was Bonnevialle, P. (2017). Operative treatment of early

done uneffective since it can totally resist the cefazolin

infection after internal fixation of limb fractures

and moreover the erythromycin, a macrolide group.

(exclusive

severe

CONFLICT OF INTEREST

fractures). Orthopaedics

No conflicts of interest have been declared.

Surgery

CONCLUSION AND RECOMMENDATIONS

10.1016/j.otsr.2016.06.019

open

Traumatology:

Research, 103(1).

doi:

This case report of SSI in a postoperative of severe

Carroll, K. C., Morse, S. A., Mietzner, T., & Miller, S.

open fracture can be used to evaluate the empirical

(2016). Jawetz, Melnick & Adelbergs medical

treatment that is used in RSD dr. Soebandi Jember

microbiology (27th ed.). New York: McGraw-Hill

since the causative agent of this infection is really

Education.

serious matter, MRSA. This report is an initial step to

Doshi, P., Gopalan, H., Sprague, S., Pradhan, C.,

do some studies in order to conclude the evidence of

Kulkarni, S., & Bhandari, M. (2017). Incidence

nosocomial infection in RSD dr. Soebandi. Hospital’s

of infection following internal fixation of open

Antibiogram is needed for having a high efficacy of

and closed tibia fractures in India ( INFINITI ): a

nosocomial infection treatment. Future research should

multi-centre observational cohort study, 1–10.

aim to identify and quantify the incidence risk of

https://doi.org/10.1186/s12891-017-1506-4

infection after treatment by the hospital moreover the

Fernandes M, Peres L, QueirozNeto A, Lima Neto J,

next level infection such as surgical site infection Staphylococcus

Turíbio F, Matsumoto M. (2015) Open fractures

aureus (VRSA). It also should aim to conclude the

and the incidence of infection in the surgical

best practices for management of infection and for

debridement

prophylactic antibiotic use to ensure a strict treatment

ActaOrtopédica Brasileira.;23(1):38-42

caused

vancomycin-resistant

374

hours

after

trauma.

at:http://dx.doi.org/10.1128/AAC.02252-17

Ghoshal, A., Enninghorst, N., Sisak, K., & Hunter, F. J. (2010). An interobserver reliability comparison

Mangala, A., Arthi, K., & Deepa, R. (2018).

between the Orthopaedic Trauma Association ’ s

Comparison of Predebridement and Debridement

open fracture classification and the Gustilo and Anderson

classification,

Cultures in Predicting Postoperative Infections in

242–246.

Compound

https://doi.org/10.1302/0301-620X.100B2.BJJ-

12(7),

10–13.

https://doi.org/10.7860/JCDR/2018/36011.11735

2017-0367.R1

Masanori Toyofuku, Tomohiro Inaba, Tatsunori

Global Guidelines for the Prevention of Surgical Site

Kiyokawa, Nozomu Obana, Yutaka Yawata &

Infection. Geneva: World Health Organization;

Nobuhiko Nomura (2016) Environmental factors

(2018). 3, Important Issues in the Approach to

that

Surgical Site Infection Prevention. Available

shape

biofilm

formation,

Bioscience,

Biotechnology, and Biochemistry, 80:1, 7-12,

from:

DOI: 10.1080/09168451.2015.1058701

https://www.ncbi.nlm.nih.gov/books/NBK536426

Metsemakers, W. J., Kuehl, R., Moriarty, T. F.,

Richards, R. G., Verhofstad, M. H. J., Borens, O.,

Gupta, S., Saini, N., Sharma, R., Kehal, J., & Saini,

… Morgenstern, M. (2018). Infection after

Y. (2012). A Comparative Study Of Efficacy Of

fracture

Pre And Post Debridement Cultures In Open

Current

surgical

and

Msed, B. N. G., Msed, C. D. J., Todd, J., Dc, E.,

Bacterial Biofilms on Implanted Suture Material Cause

xation :

https://doi.org/10.1016/j.injury.2016.09.019

Kathju S, Nistico L, Tower I, Lasko L, Stoodley P. a

microbiological concepts. Injury, 49(3), 511–522.

Fractures, 19(3), 1–7.

Are

Fractures,

Surgical

Site

Michael, C. D. R., Pt, R., … Dc, E. (2012).

Infection.

(2014);15(5):592–600.Available

Methicillin-resistant Staphylococcus aureus : an

from:

overview for manual therapists . Journal of

http://dx.doi.org/10.1089/sur.2013.016

Chiropractic

11(1),

64–76.

https://doi.org/10.1016/j.jcm.2011.12.001

Kim, P. H., & Leopold, S. S. (2012). Gustilo-Anderson Classification,

Medicine,

3270–3274.

National Collaborating Centre for Women's and

https://doi.org/10.1007/s11999-012-2376-6

Children's Health (UK). Surgical Site Infection:

Kostakioti, M., Hadjifrangiskou, M., Hultgren, S. J.,

Prevention and Treatment of Surgical Site

Hayes, C. S., Koskiniemi, S., Ruhe, C., …

Infection. London: RCOG Press; (2008) Oct.

Gorvel,

(NICE

(2014).

Bacterial

Biofilms :

Clinical

Guidelines,

No.

74.)

Development , Dispersal , and Therapeutic

Introduction.

Strategies

https://www.ncbi.nlm.nih.gov/books/NBK53735/

the

Dawn.

https://doi.org/10.1101/cshperspect.a010306

Available

from:

Oliveira, P. R., Carvalho, V. C., Felix, S., Paula, A. P.

Luther MK, Parente DM, Caffrey AR, Daffinee KE,

De, Santos-silva, J., Lucia, A., & Munhoz, L.

Lopes VV, Martin ET, LaPlante KL. (2018).

(2016). The incidence and microbiological

Clinical and genetic risk factors forbiofilm-

profile of surgical site infections following

forming Staphylococcus aureus. Antimicrob

internal fixation of closed and open fractures ଝ.

Agents

Chemother62:e02252-17.

Revista Brasileira de Ortopedia, 51(4), 396–399.

doi:10.1128/AAC.02252-17Available

https://doi.org/10.1016/j.rboe.2015.09.012 375

Orthoinfo.aaos.org.

(2019). Open

Fractures

OrthoInfo - AAOS. [online] Available at: https://orthoinfo.aaos.org/en/diseases-conditions/open-fractures/

[Accessed

Oct.

2019] Riedel S, Hobden J, Miller S, Morse S, Mietzner T, Detrick

Melnick&Adelberg's

al.

(2019).Jawetz,

medical

microbiology.

28e. McGraw-Hill Education Sun, Y., Wang, H., Tang, Y., Zhao, H., Qin, S., Xu, L., … Zhang, F. (2018.). Incidence and risk factors for surgical site infection after open reduction and internal fi xation of ankle fracture. Wolfensberger A, Sax H, Weber R, Zbinden R, Kuster S, Hombach M. Change of Antibiotic Susceptibility Testing Guidelines from CLSI to EUCAST: Influence on Cumulative Hospital Antibiograms. PLoS ONE. 2013;8(11):e79130. World Health Organization (WHO). (2016). Surgical Site Infections (SSI) Zhu, H., Li, X., & Zheng, X. (2017). A Descriptive Study of Open Fractures Contaminated by Seawater : Infection , Pathogens , and Antibiotic Resistance, 2017.

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ABSTRACT Title: A Case Report: Multitrauma After a Single Motorcycle Accident (Intracranial Hemorrhage, Acute Subdural Hematoma, Acute Subdural Hygroma, Closed Fracture Mandible, and Open Fracture Tibia Fibula Grade III A) Authors: Tania Isabella Waspodo, Silvia Husodo, Fairuz Abidatillah Meilany, Kartika Palmasari AMSA-Indonesia Patient history A 28 years old man was referred to the hospital with decrease of consciousness after a single motorcycle traffic accident. For primary survey, airway was patent, breathing was spontaneous and symmetrical. The vital signs, respiratory rate of 24x/minute, pulse rate is 84x/minute, and blood pressure is 137/76 mmHg. Visual analog scale is 4-5/10, Glasgow coma scale was 125 and pupils were anisocoria 5mm/3mm. From the physical examinations, there were laceration on the right leg, gums bleeding, and abrasions on the right face. Challenges Multitrauma is a possible life injuries so required emergency treatment. Whilst the symptoms are almost unrecognizable, the mortality rate is at an exceeding percentage. Key Findings •

Lesions that are extra axial, hyperdense, and crescent like in CT scan of acute subdural hematoma.

•

Lesions hypodense, CSF like with crescentic extra axial collections in CT scan of acute subdural hygroma.

•

Open fracture on the right proximal third tibia and fibula grade III A with laceration, edema, ecchymosis, and tenderness.

•

Segmental fracture of the right mandible with bleeding of the gums, and decrease ability to open the mouth.

Management •

Head up 30 degree and O2 via NRBM 10 lpm for acute subdural hygroma, intra cranial hemorrhage, and acute subdural hematoma.

•

The Erich Arch Bars closed reduction for segmental fracture of the right mandible.

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•

IV Cefazolin 1gr and IM Tetagam 250iu for prevent infection and tetanus. Open Reduction Internal Fixation for the open fracture of right proximal third tibia fibula grade III A.

•

IV Ketorolac 30 mg for pain management. IV Ranitidine 50 mg for compensation of gastritis the side effect of Ketorolac.

•

IVFD NS 0.9% 1500cc / 24 hours administration is performed to restore the balance of body fluids and NaCl.

•

On the 7th day, the GCS score has becoming 325. ORIF held on 8th day.

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A CASE REPORT: MULTITRAUMA AFTER A SINGLE MOTORCYCLE ACCIDENT (INTRACRANIAL HEMORRHAGE, ACUTE SUBDURAL HEMATOMA, ACUTE SUBDURAL HYGROMA, CLOSED FRACTURE MANDIBLE, AND OPEN FRACTURE TIBIA FIBULA GRADE III A)

By: Tania Isabella Waspodo1, Silvia Husodo2, Fairuz Abidatillah Meilany3, Kartika Palmasari4 2nd year medical student, 3rd year medical student, 2nd year medical student, 2nd year medical student ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION INDONESIA

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A. Introduction Trauma is still a leading cause of death and has an enormous impact on the patient's life and health systems. Motorcycle accidents are the most frequent cause of multiple trauma. According to the "WHO Global Status Report on Road Safety" more than 1.2 million people die on the world's roads every year and 50 million others are injured (World Health Organization, 2016). In Indonesia, the prevalence of traffic accidents in 2018 was 28,262 with a mortality rate of 5,914. During 2019 until June, there have been 4,180 traffic accidents with a mortality rate of 1,044 with a single traffic accident of 172 cases (Pfeifer et al, 2016). The hospital course of patients with multitrauma injuries is frequently accompanied by severe complications. Multitrauma usually presents challenging clinical scenarios with musculoskeletal injuries that are life-threatening and needs immediate management. Hemorrhagic shock is one of the central problems in patients with multitrauma and a common cause of death. (Frink et al, 2017). In this case, the patient suffered multitrauma due to traffic accidents. At first glance the patient was seen only exposed to open fractures on the right foot. However, it seems that the patient also suffered other traumas like head injury which makes the patient in need of special medical handling immediately. Based on the rare occurrence of this incident, the varied needs of treatment, and the need for close supervision of the patient to maintain and improve the patient's condition wherever possible. B. Patientâ&#x20AC;&#x2122;s History A 28 years old man with an initial of SI was referred to the hospital after a single motorcycle traffic accident. A Visual Analog Score results in 4-5/10 that describes the moderate pain. For primary survey, medical professionals present at the moment assessed the patient with a basic ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach. The results are patent breathing, in which the patient has a clear and open airway and is able to inhale and exhale properly. Breathing is spontaneous and the movement is symmetrical with a respiratory rate of 24x/minute. Pulse rate result in 84x/minute with a blood pressure of 137/76 mmHg. Glasgow Coma Scale result in 125. The patient cannot open their eyes in response to a command, emits incomprehensible sounds, and moves to localized pain. Anisocoria, or a difference in the diameter of the two pupils are found 5mm/3mm. This lateralization discovery lead to suspicion of intracranial injury.

Figure 1. Image the patientâ&#x20AC;&#x2122;s eyes with anisocoria 5mm/3mm.

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X-ray evaluation of cervical vertebrae, thorax region, and pelvic region is done in adjunction to primary surveys.

Figure 2. Image of cervical vertebrae x-ray. Interpretation: normal.

Figure 3. Image of thorax X-ray. Interpretation: normal. Pelvic X-ray

Figure 4. Image of X-ray pelvic. Interpretation: normal.

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For secondary survey, used AMPLE method to assess medical history. The patient has no allergic (A), medication (M), nor previous chronic illness for a past medical history (P). The last meal (L) the patient had done at least 8 hours before the single motorcycle accident (E). C. Examinations and Investigations Anamnesis: The patient presents with decreasing consciousness, an laceration on his right leg followed with a swelling on his right toes. This patient also has a history of fainting without vomiting. Physical Examination During physical examination of the head and neck, we found no signs of anemia/ icterus/ jaundice. The patient also has no otorrhea and rhinorrhea.

Figure 5. Image of face of the right side (left) and sinistroventral (right).

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Figure 6. Image of the patientâ&#x20AC;&#x2122;s teeth. During thorax examination, a symmetrical breathing with vesicular breathing sound is found without wheezing. No abnormalities are found during abdominal examination. On the extremities, relatively warm fingertips with a capillary refill time (CRT) < 2. Motoric and sensory abilities are hard to evaluate. Both bulbocavernosus reflex (BCR) test and tonus sphincter ani (TSA) test are positive. Physiologic reflex proved to be positive, while the pathologic effect proved to be negative. Local status: The local status of the right lower leg shows swelling, deformity, and laceration with a dimension of 5x2 cm. The wounded area is tender with a limited range of motion.

Figure 7. Image of the right lower leg from lateral view.

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Figure 8. Image of right lower leg from anterior view. Supporting studies: Head CT Scan -1cc of intracranial bleeding & subdural hematoma

Figure 9. Image of head CT scan. Interpretation: The appearance of the subdural hematoma lesions in CT scan are usually extra axial, hyperdense, and crescent like.

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- Subdural hygroma

Figure 10. Image of head CT scan. Interpretation: The appearance of the subdural hygroma lesions in CT scan are hypodense, CSF like, crescentic extra axial collections that consists purely of CSF. These collections does not contain any blood products, lacks encapsulating membranes, and shows no enhancement following contrast administration.

- Segmental fracture of right mandible

Figure 12. Image of head 3D CT scan with segmental fracture of right Mandible.

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- Open fracture proximal third dextra tibia fibula grade IIIA

Figure 13. Image of the right Tibia and Fibula CT scan. -Close fracture of right pedis

Figure 14. Image of right pedis CT scan. The case presents with a traumatic acute subdural hematoma (ASDH) and subdural hygroma which happens in the subdural space. In normal human anatomy, this subdural space does not exist. This space will only appear as a wound called intradural lesion through a mechanical separation of the dura-arachnoid interface (Wittschieber et al, 2015). A traumatic ASDH is a collection of the blood that fills the subdural

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space between internal dura mater and arachnoid. This is caused by the fact that traumatic injuries are usually mechanical trauma. Subdural hygroma is classically described as protein-rich, clear, pink-tinged, or xanthochromic fluid collections within the subdural space. Component of a subdural appears to be cerebrospinal fluid (CSF)-like. In radiology, the definition of subdural hygroma is more difficult because of the heterogenous appearance. Almost all the subdural hygroma cases caused by mechanical head injuries as seen in this case and represent rare post traumatic complication that may coexist with epidural or subdural hematomas (Wittschieber et al, 2015). In this case therapy for ASDH and hygroma are head up 30 degree and O2 via NRBM 10 lpm. The study of Bajsarowicz et al (2015) most acute traumatic subdural hematoma are managed conservatively, with 77% of the patients in study achieving a good early outcome. Only a small proportion of the conservatively managed patients will deteriorate and require surgery. The head up 30⁰ management is to decrease significantly the mean carotid pressure and decrease intracranial pressure (ICP) so it can stabilize cerebral blood flow (CBF). The O2 therapy is to resolve the hypoxia of the brain that occurs by space occupying lesion. The patient is exposed to open fracture on the proximal third of the right tibia and fibula, swelling (+), deformity (+), vulnus laceratum (+) size 5x2cm, tenderness (+), NV distal normal, ROM limited, with CT scan shows disalignment, complete oblique fracture, and normal joint. Gustilo Anderson grade III-A open fractures. Fracture complete oblique can occur because of the pressure in the form of compressions received by the bone when the patient crashes into a tree. Human bones are able to receive the most pressure in the form of compressions and are able to withstand the least pressure in the form of shears. That can happen because bones have anisotropic characteristic (Apley and Solomon, 2018). Initial therapy and management that can be done to overcome open fracture in these patients, namely cleaning debridement and immobilization with the backslab method. Furthermore, IVFD NS 0.9% 1500cc / 24hour administration is performed to restore the balance of body fluids and NaCl, inj. Cefazolin 1gr intravenously to prevent infection. (“Cefazoline”, inj. Intramuscular Tetagam as a prophylactic tetanus infection. (“Tetagam”, 2019). For further action, Open Reduction Internal Fixation (ORIF) is a surgery done to fix a bone using surgical plates, nails, screws or pins. Under general or local anesthesia, an incision is made over the fractured bone. Once the bone is placed in its proper position, screws, pins, plates or nails are attached to stabilize it. Longer bones may be repaired with a nail placed directly in the bone cavity. Patients will be expected to not eat and limit drink to clear liquids for at least six hours before the procedure. The area to be treated will be cleaned and shaved immediately prior to the surgery. (Sun et al, 2018). To treat pain after surgery given therapy by inj. Ketorolac 30 mg iv and inj. (“Ketorolac”, 2019) Ranitidine 50 mg intravenously for prophylaxis of acid aspiration during anesthesia. (“Ranitidine”, 2019) Physical examinations of the head show no signs of anemia or icterus. This means that the rate of which the red blood cells (RBCs) are broken down in the liver did not surpass the production rate of new RBCs. Billirubin, a breakdown product of hemoglobin, did not accumulate in the body, hence why the patient showed no signs of typical icterus. Essentially, this means that the patient does not have any liver problem due to the

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trauma. No blood accumulation is found in the ears as there is no laceration found in the scalp nor a fracture found in the auditory canal, specifically in the external posterosuperior region. No findings of bloody rhinorrhea also means that there are no direct trauma to the internal nasal cavity. A positive bowel sound is found in the patient which is a normal case. This means that the patient does not undergo intestinal paralysis and the gastrointestinal tract is working normally. This is also shown by a positive tonus sphincter ani (TSA) test that shows a fully working tonic contraction for anal closure. A positive bulbocavernosus reflex (BCR) test, referring to anal sphincter contraction in response to squeezing the glans penis or tugging on the Foley may indicate intact spinal reflex arcs (S2–S4 spinal segments) with afferent and efferent nerves through the pudendal nerve. The patient presents with a respiratory rate of 24x/minute (normal:16-20x/minute), an increase compared to its normal value rate due to intracranial bleeding with a volume of 1 cc. A substantial amount of blood loss, such as one in this case, may result in hemodynamic compromise occurring in the chest, abdomen, and retroperitoneum and can end up with a hemorrhagic shock condition, due to a depleted amount of effectively distributing blood volume in a body’s circulatory system. At this point, the body will not be able to match the tissue demand for oxygen and will utilize anaerobic metabolism to meet the cellular demand and avoid necrosis. This process will result in the production of ketones. In addition, the intravascular volume loss will be compensated through increasing heart rate and its contractility. Hence, both the patient’s blood pressure and respiratory rate increase beyond normal levels. Typically in this condition, the patient will have a slightly increased diastolic pressure and a decreased sistolic pressure, followed by a narrowing heart rate. However, the present case shows a blood pressure of 137/76 mmHg, in which the diastolic pressure decreases by a little and a normal heart rate 84x/minute. However, the body’s compensation for this may vary by cardiopulmonary comorbidities, age, and vasoactive medications. The designated location of mandibular fractures was based on the modified classification schemes proposed by Dingman et al. Mandibular classification segments including the parasymphysis, body, angle, ramus, condyle, subcondyle, coronoid process, and alveolar ridge, alveolar ridge fratures were defined as fractures confined to the alveolar ridge without extension into the inferior aspect on the mandible. The fracture has been classified as unifocal or multifocal, and in the multifocal group, all fractures sites were recorded including the involvement of fractures unilaterally or bilaterally (Butch, 2016).

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Figure 16. Buch, K. et al, 2016. Unifocal versus multifocal mandibular fractures and injury location. Emergency radiology, 23(2), pp.161-167. The classification of mandible according to the Dingman and Natvig Mandibular classification segments . Both unifocal and multifocal fractures were found to most commonly involve the mandibular angle. Fractures involving the parasymphyseal region as well as the mandibular body and ramus were strongly associated with the presence of additional fractures. Parasymphyseal fractures and fractures involving the mandibular ramus and body were significantly associated with multifocal mandibular fractures (Butch, 2016.) In this case there is no status that indicates the patient has suffered from mandibular fractures, however after imaging examination, it was discovered that the patient has suffered from it. The two lines of fractures found is defined as multifocal-unlateral fractures. The first line is located on the parasymphyseal with complete oblique displaced line of fractures, with involvement of the teeth. The second line is located on the mandibular angle with complete transverse displaced line of fractures (Apley and Solomon, 2018). From there, the patient is diagnosed with segmental fracture of the right mandible.

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Figure 17. Image of head 3D CT scan. D. Diagnosis This patient is diagnosed with Severe Head Injury with a GCS score of 125, with subdural hygroma and intracranial hemorrhage (ICH), and subdural hematoma. The team also found a segmental fracture of the right mandible. An open fracture on the right third proximal tibia-fibula of grade IIIA is also found. E. Treatment and Course Treatment plans The medical team planned a non-operative management for the neurological aspect of the treatment course. However, a cito Archbarr and facial reconstruction surgery is planned. Orthopedic treatments of the right lower leg include debridement, backslab, and and Open Rediction Internal Fixation (ORIF) surgery. For the right foot, the team planned bulky bandaging. The patient has been given a treatment course of Head up 30°, O2 intake via Non Re-breather Mask 10 lpm, IVFD NS 0.9% 1500cc/24 hours, an injection of Cefazolin 1gr iv, an injection of Tetagam 250iu im, an injection of Ketorolac 30 mg iv, and also an injection of Ranitidin 50 mg iv. We also plan to monitor the patient’s vital signs and Glasgow Coma Scale on an interval. B1-B6 functions should also be assessed alongside the progressivity of compartment syndrome (6P: Pain, Poikylothermia, Paresthesia, Paralysis, Pulselessness, and Pallor.). The patient’s therapy response should also be monitored thoroughly. F. Challenges Faced The challenges in this case are acute subdural hematoma, acute subdural hygroma, and grade IIIA open fracture tibia-fibula because of their complications, in which the sudden and severe bleeding causes subdural hematoma. The patient may lose consciousness and experience syncope, as in this case, but sometimes they can appear normal in a few days because of a slower rate of bleeding. Hence, there may be no noticeable symptoms after a few weeks, or even worse, might be misdiagnosed. The symptoms of this hematoma various greatly, such as headache, lethargy, dizziness, nausea, confusion, etc. These various symptoms make subdural hematoma relatively difficult to identify due to the fact that there are no specific symptoms. The mortality rate is also relatively higher at about 60% of the total reported cases. Acute subdural hygroma, on the other hand, is mostly asymptomatic with little mass effect. And so to define the diagnosis, the use of CT scan or MRI is highly required. Symptoms, if ever found, are generally unspecific such as headache, nausea, vomiting, focal neurologic, and seizure. On the other hand, the morbidity of subdural hygroma is comparatively high. This is due to the fact that it can be the predisposing factor of chronic subdural hematoma that can actually make this condition more severe (Ahn et al, 2016). Based on Gustilo classification, this type II open fracture tibia-fibula has 2-7% risk of infection from the surrounding normal floras or environment. All open fractures are by definition contaminated and must be treated as such.

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G. Discussion The case presents with a traumatic acute subdural hematoma (ASDH) and subdural hygroma which happens in the subdural space. In normal human anatomy, this subdural space does not exist. This space will only open as a wound called intradural lesion through a mechanical separation of the dura-arachnoid interface (Wittschieber et al, 2015). A traumatic ASDH is a collection of the blood that fills the subdural space between internal dura mater and arachnoid. This is caused by traumatic injuries, usually mechanical trauma. In ASDH, there is also a space-occupying lesion to increase intracranial pressure that is often complicated by co-existing injuries, including a variety of diffuse injuries, contusional hematomas, and edemas. An ASDH occurs less than 72 hours after the incident. In one study, 82% of syncope patients with acute subdural hematomas had parenchymal contusions. The severity of the diffuse parenchymal injury has a strong inverse correlation with the outcome of the patient especially affects his/her consciousness. The mortality of ASDH relatively high about 60% of the total cases. A total of 59 patients were included with 29 died. The causes of subdural hematoma are the tearing of a surface and bridging vessel. Venous bleeding can be stopped by increasing intracranial pressure (ICP) or direct compression from the clot itself. Otherwise, an arterial source up to 30% of total cases caused by rupture of small cortical arteries around <1mm in diameter. The arteries subdural hematoma likely found in temporoparietal and the venous subdural hematoma likely found in frontoparietal. Another mechanism on how the hematoma occurred is through intracranial hypotension with resultant traction on bridging veins or expansion of cerebral veins following by leakage of fluid into the subdural space. There are three mechanisms of acute subdural hematoma pathophysiology. The first mechanism is a decrease in the cerebral blood flow (CBF) immediately after the injury. Normal or restored systemic blood pressure and arterial oxygenation can suggest non systemic causes. This cerebral blood flow reduction might result from the decrease of cerebral perfusion pressure (CPP) due to intracranial pressure (ICP) increase. The second mechanism is that coagulopathy can occur in brain trauma injury, induced by stimulation tissue factor pathway, resulting in systemic bleeding tendency shortly after trauma. This coagulopathy might interfere with intracranial hematoma and might lead to worse conditions. In this condition, a high D-dimer level has been demonstrated to correlate with a poor outcome in a traumatic intracranial hematoma. And the third mechanism is the delayed deterioration that inverses correlation with elderly patients. With age, the brain will undergo atrophy and so, to compensate blood accumulation and brain swelling, it develops larger intracranial spaces. This condition occurs within 6 hours after trauma, of which, the early cerebral blood flow decrease. After about 2 weeks, synthesis of dural collagen is induced and fibroblastic growth results in the formation of a thick outer membrane over the inner dural surface, followed by encapsulation of the clot (Karibe et al, 2014). Subdural hygroma is classically described as protein-rich, clear, pink-tinged, or xanthochromic fluid collections within the subdural space. Component of a subdural collection appears to be cerebrospinal fluid (CSF)-like. If there is a mixture of blood and CSF is referred to as hemato hygroma. General morphologic types:

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1. Cystic and often multichambered formations encapsulated by a membrane. 2. â&#x20AC;&#x153;Freeâ&#x20AC;? fluid collections without any capsule. In radiology, the definition of subdural hygroma is more difficult because of the heterogenous appearance. Almost all the subdural hygroma cases caused by mechanical head injuries as seen in this case and represent rare post traumatic complication that may coexist with epidural or subdural hematomas. Subdural hygroma also can result from trauma and from cranial operations in which the arachnoid membrane is opened, leading to CSF transfer into the subdural space. A ball-valve mechanism of the arachnoid is assumed to prevent a backflow of CSF into the subarachnoid space (Wittschieber et al, 2015).

Figure 15. Wittschieber, D., Karger, B., Niederstadt, T., Pfeiffer, H., & Hahnemann, M. L. (2015). Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications. American Journal of Neuroradiology, 36(3), 432-439. In mandible fractures, the fracture lines were suspected to be caused by a force that came from lower right impact, causing the setback of segmental fracture. While the fracture lines in the mandibular angle is suspected to be caused by opposing muscle forces from the mandibular elevators and depressors, zones are created of maximal tension and maximal compression along the superior and inferior margins of the mandible, respectively.

According to the working diagnosis (segmental fracture of the right mandible), further actions to be driven out in this case is external fixation as a damage control surgery to immobilize the mandible fracture segments. There are some common technique which can be use in MMF such as Arch Bars, Ernst ligatures and Bone supported devices including intermaxillary fixation (IMF) screws, hanger plates and interact miniplates in this case the technique used is the arch bar, as the arch bar is set as the gold standard in MMF

392

(Mandibulomaxillary fixation). The bars are cut and fitted on both dentitions. The technic start by counting 18 lugs, then position the bars so the lugs open away from the crowns to allow MMF wires. The standard is to use 24-gauge stainless steel circumdental wires twisted closed in a clockwise rotation. Wires may be prestretched to lessen wire stretching and loosening after surgery. Factory-cut wires may be less sharp and may lessen the risk of puncture injury. Position the patient into maximum intercuspation, and place MMF wires or elastics. (Brennan, 2012). This immobilization action must be taken to prevent further damage caused by the movement of fracture segments and helps to make the wound healing process go well. Besides, this quick-inquick-out is used to reduce the pain which also caused by the movement of mandible fracture segments so the patient can get early nutrition intake. But beyond that, arch bar is not a definitive therapy for patients. Arch bar is used for temporary fragment stabilization in emergency cases before early total care which is mandible reconstruction as a definitive treatment. Arch bar can be used as a definitive therapy in cases where the patient suffer simple fractures, in example, the fracture segments are not comminutive, do not shift, not the segmented mandible fracture, etc. According to the diagnosis (segmental fracture of the right mandible), further actions to be driven out in this case is Closed Reduction. Closed reduction can be accomplished with a variety of techniques with and without the dentition. The technic which used is Erich Arch Bars Arch. Bars are considered the standard in MMF. These are cut and fitted on both dentitions. The technic start by counting 18 lugs, then position the bars so the lugs open away from the crowns to allow MMF wires. The standard is to use 24-gauge stainless steel circumdental wires twisted closed in a clockwise rotation. Wires may be pre-stretched to lessen wire stretching and loosening after surgery. Factory-cut wires may be less sharp and may lessen the risk of puncture injury. y Position the patient into maximum intercuspation, and place MMF wires or elastics. In case intended for long term use, patients must be aware of the risks to teeth and periodontum and have adequate follow-up care (Brennan, 2012). These fracture lines were suspected to be caused by a force that came from lower right impact, causing the setback of segmental fracture. While the fracture lines in the mandibular angle is suspected to be caused by opposing muscle forces from the mandibular elevators and depressors, zones are created of maximal tension and maximal compression along the superior and inferior margins of the mandible, respectively.

393

Another further action taken in this case is Closed Reduction. Closed reduction can be accomplished with a variety of techniques with and without the dentition. The technique which used is Erich Arch Bars fixation. Arch Bars are considered the standard in MMF. These are cut and fitted on both dentitions. Tis technique starts by counting 18 lugs, and then position the bars so that the lugs open away from the crowns to allow MMF wires. The standard is tu use 24-gauge stainless steel circumdental wires twisted closed in a clockwise rotation. Wires may be prestretched to lessen wire stretching and loosening after surgery. Factorycut wires may be less sharp and may lessen the risk of puncture injury. y Position the patient into maximum intercuspation, and place MMF wires or elastics. In case intended for long term use, patients must be aware of the risks to teeth and periodontum and have adequate follow-up care (Brennan, 2012). In this case, the doctor diagnosed that open fractures of the tibia and fibula from the patient is included in the Gustilo Anderson III A classification, consisting of displacement, periosteum tears and occurs in places with high contamination, namely the highway. The mechanism of injury involves high energy, it can be seen from many trauma experienced by patients and decreased consciousness. For operative therapy the doctor performs 2 times, for the first therapy, the doctor performs debridement as a damage control surgery, after about 5 days later the doctor performs ORIF surgery. The reason why ORIF is done 5 days after being bred is to avoid infection because the ORIF plate is a good medium for bacterial growth and supports bacteria to form biofilms. Therefore, ORIF is not directly performed on patients who have just had debridement, it must be ensured beforehand the signs of inflammation and pro-inflammatory cytokines have decreased.

Figure 18. Image of 3D CT scan head.

394

H. Conclusion In this case, the patient is diagnosed as a multiple trauma patient with details of: 1. Severe head injury with 125 as the GCS score, subdural hygroma, intra cranial hemorrhage (ICH) more specifically is subdural hematoma. In this case, the therapy for acute subdural hematoma and hygroma are head up 30 degree and O2 via NRBM 10 lpm. 2. Segmental fracture of the right mandible. In this case, the further action taken before the definitive treatment is done is external fixation to immobilize the fracture fragments. The technique which is used is Arch Bars as the Arch Bars is considered as the gold standard in MMF. 3. Open fracture proximal third dextra tibia fibula grade IIIA. IVFD NS 0.9% 1500cc/ 24 hour administration is performed to restore the balance of body fluids and NaCl. Injection of Cefazolin 1gr intravenously was intended to prevent infection. Injection of Intramuscular Tetagam was given as a prophylactic tetanus infection. For further action, Open Reduction Internal Fixation (ORIF) is a surgery that will be done to fix a bone using surgical plates, nails, screws or pins. Under general or local anesthesia, an incision is made over the fractured bone For pain management, the patient was given an injection of Ketorolac 30 mg intravenously, and ranitidine 50 mg iv to compensate a side effect of gastritis. The patient has already been in the intensive care for 7 days. On the 7th day, the GCS score has had an improvement, becoming a score of 325 in result of all the treatments. ORIF for the open fracture right proximal third tibia fibula will be held on day 8. The first day is counted from the first time the patient entered the Emergency Room. References Ahn, J. H., Jun, H. S., Kim, J. H., Oh, J. K., Song, J. H., & Chang, I. B. (2016). Analysis of risk factor forthe development of chronic subdural hematoma in patients with traumatic subdural hygroma. Journal of Korean Neurosurgical Society, 59(6), 622. Bajsarowicz, P., Prakash, I., Lamoureux, J., Saluja, R. S., Feyz, M., Maleki, M., & Marcoux, J. (2015). Nonsurgical acute traumatic subdural hematoma: what is the risk?. Journal of neurosurgery, 123(5), 1176-1183. Buch, K., Mottalib, A., Nadgir, R. N., Fujita, A., Sekiya, K., Ozonoff, A., & Sakai, O. (2016). Unifocal versus multifocal mandibular fractures and injury location. Emergency radiology, 23(2), 161-167.

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Cannon, J. W. (2018). Hemorrhagic shock. New England Journal of Medicine, 378(4), 370-379. Cefazoline. (2019). In MIMS Onlne. Retrieved from http://www.mimsonline.com.au, on September 29, 2019. Costello, M. S., Stevens, S., & Samy, R. N. (2017). Unilateral Hearing Loss and Otorrhea. JAMA Otolaryngologyâ&#x20AC;&#x201C;Head & Neck Surgery, 143(7), 727-728. Cross III, W. W., & Swiontkowski, M. F. (2008). Treatment principles in the management of open fractures. Indian journal of orthopaedics, 42(4), 377.

Folkerts, D. J., McPhee, K. L. F., Johnson, G. R., & Gack, T. M. (2016). U.S. Patent No. 9,392,955. Washington, DC: U.S. Patent and Trademark Office. Karibe, H., HayasHi, T., Hirano, T., KaMeyaMa, M., Nakagawa, A., & Tominaga, T. (2014). Surgical management of traumatic acute subdural hematoma in adults: a review. Neurologia medicochirurgica, cr-2014. Ketorolac. (2019). In MIMS Onlne. Retrieved from http://www.mimsonline.com.au on September 29, 2019. Kim, P. H., & Leopold, S. S. (2012). Gustilo-Anderson classification. Ranitidine. (2019). In MIMS Onlne. Retrieved from http://www.mimsonline.com.au on September 29, 2019. Salinas, N. L., & Brennan, J. A. (2012). Penetrating and blunt neck trauma. Resident Manual of Trauma to the Face, Head and Neck, 164-73.

Sun, Y., Wang, H., Tang, Y., Zhao, H., Qin, S., Xu, L., ... & Zhang, F. (2018). Incidence and risk factors for surgical site infection after open reduction and internal fixation of ankle fracture: a retrospective multicenter study. Medicine, 97(7). Tetagam. (2019). In MIMS Onlne. Retrieved from http://www.mimsonline.com.au on September 29, 2019. Watts A, Warwick D. Injuries of the elbow and forearm. In: Blom A, Warwick D, Whitehouse M, editors. Apley & Solomonâ&#x20AC;&#x2122;s System of orthopaedics and trauma. 10th ed. Boca Raton, Florida. CRC Press. 2018

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Wittschieber, D., Karger, B., Niederstadt, T., Pfeiffer, H., & Hahnemann, M. L. (2015). Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications. American Journal of Neuroradiology, 36(3), 432-439.

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Grade III hypovolemic shock following antepartum hemorrhage in a patient with placenta previa and placenta accreta spectrum: a clinical case presentation Universitas Gadjah Mada 1

Azyumar Luthfi , Deas Makalingga1, Enrique Aldrin1, Achmad Daynamus1 1

Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada

ABSTRACT Patientâ&#x20AC;&#x2122;s History A 40-year-old pregnant woman, G4A1P2 came with a referral from RS Nyi Ageng Serang Kulon Progo, D.I Yogyakarta. This patient was referred with a diagnosis of antepartum hemorrhage with placenta previa and suspected for placenta accreta along with anemia condition. The fetal heartbeat showeda positive result and the fetus was actively moving. Challenges Patient suffered severe hemorrhage, anemia, and hypotension Hypovolemic shock grade III on maternal ward with blood loss around 1500 ml Bleeding control was unable to be done without surgery. Hysterectomy was chosen to control bleeding and treat placenta accreta spectrum Multidisciplinary team deployment, emergency team was handling the resuscitation and stabilization the patient while the ob-gyn doctor evaluated the next move Key Findings Patient suffered severe hemorrhage that caused hypovolemic shock grade III Placenta previa and accreta spectrum Cesarean section and hysterectomy were performed The patient survived the emergency condition

Management The emergency team attempted to stabilize the patient. Fluid resuscitation and blood transfusion were performed, vasoconstrictor was given, and Ambu bag was used to maintain oxygen perfusion. After stabilization, the patient was moved to OK for SC. Hysterectomy was also performed to control the excessive bleeding by the consent of the patientâ&#x20AC;&#x2122;s husband.

398

Grade III hypovolemic shock following antepartum hemorrhage in a patient with placenta previa and placenta accreta spectrum: a clinical case presentation

Azyumar Luthfi1, Deas Makalingga1, Enrique Aldrin1, Achmad Daynamus1

Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada

399

INTRODUCTION

Shock could arise as a complication due to antepartum hemorrhage in pregnancy. Antepartum hemorrhage includes in most frequent emergencies in obstetric which remains a major cause of maternal dan perinatal death even in the modern era[1]. In Indonesia, antepartum hemorrhage incidence is around 3% of all deliveries. This along with postpartum hemorrhage, comprise the main leading cause (40-60%) of maternal mortality rate in Indonesia[2]. Twenty percent cases of antepartum hemorrhage is caused by abnormally situated (partially or completely) of the placenta in the lower uterine segment known as placenta previa[3,4]. Priyanka Tyagi (2016) summarized the classification of placenta previa into 4 classes as follows: “

Type 1 or Low Lying: Encroaches lower uterine but does not reach internal os. Type 2 or Marginal: Reaches margin of the internal os but does not cover it. Type 3 or Partial: Partially covers the internal os. Type 4 or Total or Central: Completely covers the internal os.”[4] Genovese (2012) stated that “risk factors for the development of placenta previa

include prior cesarean delivery, pregnancy termination, intrauterine surgery, smoking, multi-fetal gestation, increasing parity, maternal age, and the rising rates of Caesarean section” [5]. Prior cesarean delivery and rising rates of cesarean section are also risk factors for the emergence of placenta accreta spectrum, including placenta increta, placenta precreta, and placenta accreta, in women having placenta previa [6]. We present an emergency situation in which the patient had grade III hypovolemic shock following antepartum hemorrhage caused by placenta previa totalis along with placenta accreta spectrum. This case is declared as an emergency based on the assessment using the Early Warning Scoring (EWS) system which implemented in RSUP Dr. Sardjito D.I Yogyakarta. Emergency state will be declared when a patient’s EWS score is>7. In this case, the maternal ward had done some assessment to the patient thus activated Tim Medis Emergensi RSUP Dr. Sardjito. Afterward, Tim Medis Emergensi (TME), the medical emergency team, assisted ob-gyn team in the maternal ward for resuscitation and stabilization of the patient before transported to Operatiekamer (OK).

400

CASE REPORT

Patientâ&#x20AC;&#x2122;s history A 40-year-old pregnant woman came to RSUP Dr. Sardjito with a gravid status G4A1P2. The patient came with a referral from RS Nyi Ageng Serang Kulon Progo, D.I Yogyakarta. This patient was referred with a diagnosis of antepartum hemorrhage with placenta previa and suspected for placenta accreta along with anemia condition. The fetal heartbeat showed a positive result and the fetus was actively moving. The referral status of this patient showed some intervention to stabilize the patient before mobilization such as injection of tranexamic acid 500 mg, oral nifedipine 10 mg, and 500cc intravenous RL for bleeding and hemodynamic control. Injection of ondansetron also given to control the vomiting status of the patient in order to prevent fluid loss. Dexamethasone injection is also given to suppress inflammation reaction so it would not worsen this patient's hemodynamic status. Thereafter, the patient was mobilized to RSUP Dr. Sardjito. This pregnancy was planned to be terminated at 37 weeks of pregnancy. Six hours after arrival in RSUP Dr. Sardjito. This patient was having massive bleeding and losing consciousness. Grade III hypovolemic shock status was stated and the emergency team was deployed to control bleeding before then mobilized to the OK for Sectio Caesarea (SC) and hysterectomy.

Examination, investigation, and diagnosis A physical examination conducted right after the arrival of this patient with the result; blood pressure was 116/75 mmHg, heart rate was 109x/minute, respiration rate was 20x/minute, temperature was 36,3 degrees Celcius and intact amniotic membrane. This patient had no history of diabetes, heart disease, hypersensitivity, or hypertension. This patientâ&#x20AC;&#x2122;s 3 previous pregnancies showed that the first pregnancy ended up with abortion without curettage in 2013, the second abortion ended up with abortion with curettage in 2015 and the third pregnancy successfully delivered with cesarean section surgery in 2017. Obstetric examination by using USG showed a single fetus with horizontal presentation, fetus head on the left side, and back of the fetus facing superior part of the uterus. The placenta was shown at the corpus anterior of the uterus, expanding into the inferior part of the uterus

401

and enclosedinternal os. The result of the USG examination also showing that there was an interruption of hyperechoic border between the bladder and the serous part of the uterine.

Figure 1: USG Result on 24th of September, 2019; 10:58 AM

By this result, extra precautions were stated such as risk of injury, risk of infection and the priorities were set to manage safety conditions for maternal and fetus. By this result, the diagnosis of placenta previa totalis with placenta accreta spectrum could be stated. After diagnosed, the patient was moved to the maternal ward for observation

402

Table 1: PAI score The patient had a Placenta Accreta Index (PAI) score as follows: Parameter

Status

Score

Sectio Caesarea

1 time

Lacuna

Grade III

3,5

0,5 mm

Anterior Placenta Previa

Present

Bridging Vessel

Present

0,5

Sagittal Smallest Myometrial Thickness

Total

69 %

Interpretation

High probability of Invasion

Further examination was conducted in the maternal ward. Consciousness of the patient is good. Eyeâ&#x20AC;&#x2122;s conjunctiva showed anemia sign by its pale color and there was no sign of icteric condition. Lung expanded symmetrically and heart sound showed regular S1-S2. Inspekulo examination was conducted with the result; smooth vaginal wall, intact cervix, no opening, no bleeding, and positive stolsel. Observation continued with the precaution of bleeding A few hours later, the patient complained about massive bleeding from the vagina. The patient also felt a strong contraction on the lower abdomen. The general condition of the patient looked anxious. Blood pressure was unremarkable, pulse 190x/minute and respiration rate 30x/minute. The patient started to lose consciousness and had hypovolemic shock grade III by antepartum bleeding. The emergency team was called to stabilize the patient's condition.

Treatment The emergency team immediately check for oxygenation and ventilation. Ambu bag is used to maintain oxygen perfusion. Vasoconstrictor was given to limit bleeding without giving an excessive load of stimulant for the heart. Blood transfusion was continued while

403

also giving fluid resuscitation. Re-SC was recommended immediately to save maternal and fetal conditions. After stabilization, this patient was moved immediately to OK for re-SC. Re-SC procedure was given with an indication of placenta previa that made it impossible to deliver pervaginal. Observing the patientâ&#x20AC;&#x2122;s condition with hypovolemic shock, this procedure was necessary to be carried out immediately without a multi-discipline conference as it should for delivery planning. Bleeding control became the first priority during surgery considering the patientâ&#x20AC;&#x2122;s hemodynamic status. The patient followed a surgical procedure, hysterectomy supracervical, to excise the corpus uteri which started at 17.30 and finished roughly at 20.00 after being resuscitated from the 3rd grade hypovolemic shock. A cefazolin antibiotic was used before the surgical procedure. The incision was done from median line up to three-finger width from the umbilicus. The incision was deepened a layer by layer until parietal peritoneum. From the surgical exploration, the uterus size was normal and the lower segment of uterus seemed to adhere to the urinary bladder. Placenta appeared as penetrating the myometrium in the lower segment of uterus with active bleeding from the placenta. Therefore, it was decided to perform a hysterectomy. A longitudinal incision was done to the corpus uteri. The baby was delivered successfully. The placenta was delivered manually. Inspection was conducted and there was a finding of placenta invasion through myometrium at the lower segment of uterus with adherence to the bladder. Active bleeding found around placental bed which then consulted for hysterectomy for effective bleeding control. Hysterectomy decision then taken followed by adhesiolysis between uterus and bladder. Bleeding control and vessel suturing was taken and then abdomen closing layer by layer with suturing. Surgery finished. During surgery, to confirm patency of bladder after adhesiolysis, urologist took buli test by giving 200 cc NaCl 0,9% and no leakage found. Urinary catheter also replaced by urologist.

Challenges Faced First-hand observation without prior training to emergency in hospital We were studying the case by observing directly and through the medical record of the patient. However, all of the authors are still preclinical medical students that require guidance from the residents at the TME and wards.

404

Maternal previous bleeding and hemodynamic status This patient had suffered a severe bleeding condition along with anemia Hemoglobin status. This condition is very life-threatening. Considering the Hb level of this patient was only 7gr/dL and tension dropping, prolonged of this condition could create organ system failure by lack of oxygen perfusion. The fetal condition of this patient is also at risk of perfusion. Correction was needed to be done in cito. Asses the amount of bleeding on this patient, blood transfusion with target to reach Hb level 10 gr/dL Hypovolemic shock grade III on maternal ward Maternal bleeding condition was getting worse. The blood loss was estimated at around 1500 ml and a lot of blood spilled out on the floor. Blood pressure was no longer measurable. Increasing heart rate and respiration rate indicated the body reactions as a means to compensate for this hemodynamic condition. The patient started to lose consciousness. It had been very critical for the patient. Between stabilization or rapid mobilization, one of them was needed to be taken first. Distance between the maternal ward and the OK is quite far so the patient needed to be prepared enough for mobilization. Bleeding control pre and post-surgery Invasive bleeding control was unable to be done without surgery. Hemodynamic control was the only choice to keep the patient alive. After Re-SC, massive bleeding happened and it then controlled by hysterectomy. Curettage was not an option anymore to treat placenta accreta but it cost infertility to the patient. Multidisciplinary team deployment With this kind of case, normally multiple-disciplinary meeting between doctors needed to be done to decide the procedure of delivery. But in this kind of emergency decision need to be made, the team of emergency from anesthesiology act to control the patient's status and Obsgyn doctor evaluate the next move for delivery. The first priority is the maternal condition even fetal has a high probability to live by 34 weeks of gestation.

405

DISCUSSION

Clinical Procedure Placenta accreta spectrum is an abnormally adherent placenta to the uterine wall thought to be due to the absence of Nitabuchâ&#x20AC;&#x2122;s layer. The villous tissue is attached directly to the myometrium without intervening decidua. The prevalence of placenta accreta spectrum is 0.17% (95% confidence interval, 0.14-0.19).[7] Placenta previa is another complication in obstetrics that is characterized by abnormal position of placenta that covers the internal ostium of cervix. The term placenta previa totalis describes a complete covering of placenta over the internal ostium of cervix. The prevalence of placenta previa among deliveries is 1.24% (95% confidence interval, 1.12-1.36).[8] One complication placenta previa is common to be found with antepartum hemorrhage. 5 in 1000 pregnancies worldwide are found with placenta previa and 51,6 % of the case followed with antepartum hemorrhage. Bleeding condition could be found started from trimester 2 until trimester 3. Itâ&#x20AC;&#x2122;s not rare that pregnancies with this condition will end up with preterm cesarean section and followed with hysterectomy. [8] An actively bleeding condition of this pregnancy is potential to be an emergency in obstetric. The goals for bleeding condition are to : 1. Maintain the stability of maternal hemodynamic condition 2. Asses and determine if emergency cesarean section is indicated. Maternal and fetal assessment is the priority in the to-do list. Heart rate, respiration rate, oxygen saturation, and urine output are obligatory to be monitored. In our case, emergency condition was happening at the time pervaginal bleeding started. Before bleeding happened, the patient was given a transfusion to correct Hb level from 7 gr/dL to reach a minimum of 10 gr/dL. Bleeding started to get uncontrolled so then hemodynamic status need to be controlled. Maternal status is the first priority in this case because before the patient is determined for any cesarean section, maternal condition is the key for further steps for this pregnancy. Lack of perfusion could be lethal for the fetus caused by tension dropping on maternal status. [9] Hypovolemic shock following the bleeding condition is called hemorrhagic shock. [10] The patient started to show signs of grade III of the shock as the bleeding continued. Hemodynamic treatment as given on this condition is purposefully only to bring back

406

perfusion status into normal state. Double IV line were inserted and 2 RL were infused along with continued transfusion. This intervention gave sign of improvement by increasing the blood pressure into 80-100 mmHg of systolic pressure.

Table 2: Grading of hemorrhagic shock.[11]Data from: Mutschler A, Nienaber U, Brockamp T, et al. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflectclinical reality? Resuscitation 2013,84:309â&#x20AC;&#x201C;313.

Blood transfusion on a patient need to be directed by the losing volume of the blood over time and hemodynamic parameter such as blood pressure, maternal and fetal heart rate and, hemoglobin. Balance between blood transfusion and fluid infusion is very important to prevent any hemodilution that could impair or even worsen oxygen perfusion. Ambu bag is also used to support ventilation. After stabilization, the patient needs to be checked for any indication of cesarean delivery. Those indication of cesarean delivery are: 1. Active labor 2. Fetal heart rate non-responsive to resuscitation 3. Severe and significant bleeding which causing maternal hemodynamic status cannot be achieved and maintained

407

4. 34 weeks of gestation with significant bleeding. By the assessment, this patient status fulfills severe and significant bleeding for 34 weeks of gestation even though hemodynamic status has achieved after resuscitation. This indication leads to emergency Re-SC. Cesarean section is always indicated for placenta previa with a viable fetus. Surgeon should try to avoid the placenta when entering the uterus. If the placenta is incised it could cause such a hemorrhage from fetal vessels that could end up with neonatal anemia.[9] The most indication for hysterectomy procedure is massive uterine hemorrhage that unable to be controlled with conservative treatment. This kind of hemorrhage accounts for about 30-50% cause of peripartum hysterectomy.[12]

Early Warning System The maternal mortality rate in Indonesia showed 307 deaths over 100.000 deliveries based on Survei Antar Sensus (SUPAS), inter-census survey, in 2015. [13] If we compared this number to beforehand, Indonesia had shown quite a remarkable effort reducing its number from 359 in 2012[14] to 307 in 2015. However, Indonesia also still has a long way to reach MDG 2015â&#x20AC;&#x2122;s target which is 110 deaths over 100.000 deliveries.

[13]

Based upon this,

implementing the Early Warning System especially in Obstetric field holds an important role. RSUP Dr. Sardjito has implemented this Early Warning System since 2015. Early warning system is a system or regulation to monitor patient conditionâ&#x20AC;&#x2122;s deterioration and assure the resuscitation is performed effectively for the emergency patient including a cardiac arrest incidence[d]. Early warning system which is implemented in RSUP Dr. Sardjito is integrated with a code for rapid response system for emergency incidence and cardiac arrest termed code blue. This system along with code blue, cover all areas of the hospital for 24 hours a week except for areas which already have optimal resuscitation system such as intensive care unit and emergency ward[d]. Early warning system is also equipped with early warning scoring (EWS). Early warning scoring is an instrument developed to anticipate for deterioration of patientâ&#x20AC;&#x2122;s condition by measuring the status of the patient, that consists of respiration rate, O2 saturation, usage of breathing aid, body temperature, systolic and diastolic blood pressure, heart rate, consciousness, pain, discharge/lochia, and proteinuria. Each of the statuses has its range and scores that sums up to the final score. If the score is 7 or higher, the activation of

408

code blue is initiated. A team composed of an anesthesiology resident and a trained nurse from the TME is sent to the location. Thus, an efficient medical resuscitation can be performed, assisting the wardâ&#x20AC;&#x2122;s physician on duty and patient specialist doctors. Furthermore, early warning scoring helps in determining patients who require urgent medical care or only minor medical care and aiming in determining further management of the patient whether the patient should stay in the ward with a particular patient specialist doctor or transferred to high care unit, intensive care unit or into palliative care. Emergency cases could arise anytime anywhere in the hospital, not only affecting the patient but also the family of the patient, visitors or the medical staffs. Therefore, it would be best if every hospital could implement early warning system as early detection and rapid response system to any medical emergency[e]. Early warning system in RSUP Dr. Sardjito is easy to understand because of the simple scoring sheet and accessible from smartphone which has internet connection, so any medical doctors or trained people could utilize and and estimating additional management before patient condition deteriorate. This early warning system also has a broad spectrum covering 3 types of patient from adults, children, and maternal. This way, the analysis will be more comprehensive and adjusting with the patient. In this clinical case presentation, our main topic is emergency in obstetric field therefore the use of early warning scoring for obstetric would be useful. Here we present the Obstetric Early Warning Scoring system guide and scoring sheet which has been published in the form of poster.

409

(a)

(b)

Figure 2: RSUP Dr. Sardjito Early Warning Scoring (EWS) system guide poster. [15] (a) Obstetric Patient EWS Guide (b) Scoring Sheet for Obstetric EWS

Based on Modified Early Obstetric Warning Scoring (MEOWS), the patient scored 17 points (with some parameters unmeasured) that indicated the urgent response of TME. The MEOWS score was as follows: Consciousness: Unresponsive, scored 3 BP: unmeasured HR: 190 beats per minute, scored 3 RR: 30 breaths per minute, scored 3 SpO2: unmeasured Respiratory aid: yes, scored 2 Pain: positive, scored 3 Discharge: bleeding through the vagina, scored 3 Body temperature: unmeasured

410

Lesson Learnt In this case, we learned that a lot of factors could affect the pregnancy of a mother. Placenta accreta spectrum and placenta previa is a form of abnormal placentation result in pregnancy. Both conditions could coexist at the same time as this case and increase the risk of hemorrhage. From the first time this patient diagnosed with abnormal placentation, normal pervaginal delivery could not be conducted. Then extra precaution is given to encounter lifethreatening risk not only hemorrhage but also infection and emergency preterm delivery. Antepartum hemorrhage could happen without any sign that leads into it. By our case, we found that after arrival in RSUP Dr. Sardjito and following maternal and fetal safety management had been done. This patient already had a stable state without any sign of bleeding. Her blood pressure was normal. The only abnormal sign was low Hb level and signs of anemia. A few hours later we found that the patient was having a massive hemorrhage accompanied by hypovolemic shock while the blood pressure was dropping. Time and emergency management are very important in a life-threatening condition. Priorities need to be set before doing any intervention to the patient. Existence of teams that could manage the emergency situation is even more important. Tim Medis Emergensi, RSUP Dr. Sardjitoâ&#x20AC;&#x2122;s emergency team, and also the ob-gyn team handled this life-threatening scenario. In this case, in a hypovolemicshock condition, this patient required to be moved to the OK for delivery. Stabilization such as fluid resuscitation before mobilization is the key to support the life condition of the patient. Surgery planning involves a very complex process and prediction. Emergency status of the patient on the maternal ward before was only Re-SC emergency. But at the OK, it turned out that further intervention, in this case, hysterectomy needed to be done for bleeding control. Explanation, informed consent, and preparation were done on-the-spot. Emergency needs should be prioritized above that patient autonomy even though consent was given by the patientâ&#x20AC;&#x2122;s husband.

411

CONCLUSION Although placenta previa is acommon placental abnormality, its occurrence often followed by antepartum hemorrhage which could be life-threatening. The presence of recurrence antepartum hemorrhage in placenta previa should be addressed and controlled. Planned delivery to stop the deterioration of the patient caused by recurrent bleeding should be done. Constant monitoring for any signs of worsening to rapidly identify emergency provides a room to take immediate action before the condition of the patient get any worse. The existence of a medical emergency team that stands by for any emergency happened in wards, that focuses on activation of hospital code blue and resuscitation, and does not included in other health services, namely TME helps in an emergency situation such as massive antepartum hemorrhage in a similar way to the case we presented.

412

APPENDIX 1. Yadav M, Mehta K, Choudary V. A study of antepartum hemorrhage and its maternal and perinatal outcome at tertiary care hospital in western rajasthan. Journal of Medical Science and Clinical Research. 2019;7(9):81. 2. Trianingsih I, Mardhiyah D, Susila Duarsa A. Faktor-faktor yang berpengaruh pada timbulnya kejadian placenta previa. Jurnal Kedokteran Yarsi [Internet]. 2015 [cited 29

September

2019];23(2):103.

Available

from:

http://academicjournal.yarsi.ac.id/index.php/jurnal-fk-yarsi/article/view/115 3. Gul S, Abrar S, Jamal T, Rana G, Majid A, Iqbal M. Association between placental abruption and caesarean section among patients at khyber teaching hospital peshawar. Journal of Ayub Medical College (JAMC) [Internet]. 2016 [cited 29 September 2019];28(1):172.

Available

from:

https://jamc.ayubmed.edu.pk/index.php/jamc/article/view/488 4. Tyagi P, Yadav N, Sinha P, Gupta U. Study of antepartum haemorrhage and its maternal

and

perinatal

outcome.

International

Journal

Reproduction,

Contraception, Obstetrics, and Gynecology [Internet]. 2016 [cited 29 September 2019];5(11):3972-3973.

Available

from:

https://www.ijrcog.org/index.php/ijrcog/article/view/372 5. Genovese F, Marilli L, Benintende G, FamĂ A, Vizzini S, Carbonaro A, Palumbo M, Pafumi C. Asymptomatic complete placenta previa: a case report and review of literature. Research in Obstetric and Gynecology [Internet]. 2012 [cited 29 September

2019];11(3):30.

Available

from:

https://pdfs.semanticscholar.org/200c/abed589f41731e76f1749a003c1a8aaf7661.pdf 6. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Placenta accreta spectrum [document on the internet]. Massachusetts, USA; 2018 [cited 2019 Sept 29]. Available from: https://www.acog.org/Clinical-Guidanceand-Publications/Obstetric-Care-Consensus-Series/Placenta-AccretaSpectrum?IsMobileSet=false 7. Jauniaux, E., Bunce, C., GrĂ¸nbeck, L. and Langhoff-Roos, J. (2019). Prevalence and main outcomes of placenta accreta spectrum: a systematic review and meta-analysis. American Journal of Obstetrics and Gynecology, 221(3), pp.208-218. 8. Fan D, Wu S, Wang W, Xin L, Tian G, Liu L et al. Prevalence of placenta previa among deliveries in Mainland China. 2019.

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9. Lockwood C, Russo-Stieglitz K. Placenta previa: Management [Internet]. Uptodate.com.

2019

[cited

September

2019].

Available

from:

https://www.uptodate.com/contents/placenta-previa-management#H4767361 10. Gaieski D, Mikkelsen M. Definition, classification, etiology, and pathophysiology of shock in adults [Internet]. Uptodate.com. 2019 [cited 30 September 2019]. Available from:

https://www.uptodate.com/contents/definition-classification-etiology-and-

pathophysiology-of-shock-in-adults?search=hypovolemicshock&source=search_result&selectedTitle=4~150&usage_type=default&display_ra nk=4#H2750702 11. American College of Surgeons. Advanced trauma life support. Chicago, IL: American College of Surgeons; 2018. 12. Carusi D. Peripartum hysterectomy for management of hemorrhage [Internet]. Uptodate.com.

2019

[cited

September

2019].

Available

from:

https://www.uptodate.com/contents/peripartum-hysterectomy-for-management-ofhemorrhage?topicRef=6809&source=see_link#H4 13. Badan Kependudukan dan Keluarga Berencana Nasional. Survei Demografi dan Kesehatan Indonesia 2012. Jakarta: Badan Kependudukan dan Keluarga Berencana Nasional; 2013 p. 226. 14. Stalker P. Millenium Development Goals [Internet]. 3rd ed. Jakarta: Badan Perencanaan Pembangunan Nasional; [cited 30 September 2019]. Available from: https://www.undp.org/content/dam/indonesia/docs/MDG/Let%20Speak%20Out%20f or%20MDGs%20-%20ID.pdf 15. Kementerian Kesehatan Republik Indonesia RSUP Dr. Sardjito. Panduan Early Warning System dan Code Blue System. Yogyakarta: Kementerian Kesehatan Republik Indonesia RSUP Dr. Sardjito; 2017

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CASE REPORT: UTERINE ATONY AS ONE OF THE POSTPARTUM HEMORRHAGES AND THE PROPOSED USE OF TAMPON BALLOONS Joue Abraham Trixie, Reynaldi Allen AMSA-Universitas Kristen Indoneia

A pregnant woman comes with a non-typical complaint. New diagnoses can be made immediately after surgery. As a result, the patient's uterus must be removed. Based on guidelines for the management of uterine atony in Indonesia, there is no use of balloon tampons.

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CASE REPORT: UTERINE ATONY AS ONE OF THE POSTPARTUM HEMORRHAGES AND THE PROPOSED USE OF TAMPON BALLOONS

Joue Abraham Trixie Reynaldi Allen

Asian Medical Students Association Indonesia Universitas Kristen Indonesia (AMSA-UKI)

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1. Introduction Bleeding after childbirth is excessive bleeding after the birth of a baby. This condition is the leading cause of maternal death. About 1 to 5 percent of women have postpartum hemorrhage and generally more on Caesarean section. Postpartum bleeding usually occurs after the placenta has been removed. Get back blood after the birth of a single baby through vaginal delivery is about 500 ml (or about half a liter). When undergoing a Caesarean section, you will bleed about 1000 ml (or about one liter). Postpartum bleeding occurs right after delivery, but can also occur later. There are many things that cause postpartum bleeding. To remember, it's known as "4 Tâ&#x20AC;&#x2122;s" as tone, tissue, trauma, and thrombosis. The most common cause is uterine atony, the failure of myometrial muscle fibers to contract after the birth of a fetus. This condition can cause severe bleeding and hypovolemic shock. Poor myometrial contractions can result from fatigue due to prolonged labor or rapid labor, especially if stimulated. The purpose of this paper is to show a real example of a case of postpartum bleeding, namely uterine atony, and to promote one method to be added in the guidelines for management of uterine atony in Indonesia. 2. Patientâ&#x20AC;&#x2122;s History A pregnant woman with 34 weeks gestation comes to the emergency obstetric care because she was referred. The patient arrived at 4:21 a.m. From the previous hospital, the patient was declared to have placenta previa. The patient and husband claimed that they had bleeding a little from last night. However, there is no heartburn and pain. When the patient arrives, there is already a heartburn. The patient and husband forget the last menstruation period. The patient has a history of obstetrics, giving birth 1 time normally. Female sex, with birth weight is 2800 grams, with age now is 8 years. The results of the examination showed that the patient's blood pressure was 130/80 mmHg. Systematic examination (head to toe) within normal limits. Inspection of internal organs, no opening was found, but fluorine was found. From the history and physical examination, the patient's diagnosis was G3P1A1 Pregnant 34 weeks intra-uterine fetus, single and alive with a history of antepartum hemorrhage and contractions. Management given in the emergency room is tocolytic, hypobach 2 x 1, nifedipine when blood pressure rises. An ultrasound and proteinuria check are planned. The same day an ultrasound was performed. The following results are obtained. 1) Single fetal intrauterine life, head presentation, 2) left back, 3) fetal heart rate (+), 4) Sufficient ICA, 5) Total placenta covering ostium uteri internum, 6) BPD 8.6 ~ 34 + 6 weeks, 7) HC 31.4 ~ 35 + 2 weeks, 8) AC 29.3 ~ 33 + 2 weeks, 9) FL 6.5 ~ 34 weeks, 10) estimated fetal weight 2291 grams (+/- 334 grams), 11) Estimated parturition is January 1, 2019, 12) G3P1A1 is pregnant 34 + 2 weeks with antepartum hemorrhage.

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Figure 1. Ultrasound results

On the second day the patient was in the hospital, bleeding in the birth canal was reduced. There are no significant complaints. Physical examination results are also within normal limits. Likewise on the third day. Patients only complain of nausea and are given ondancetron when needed. At 22:15 p.m the patient suddenly complained of nausea, vomiting, and heartburn. Patients were given ranitidine and ondancetron from the attending physician. On the third day, at 02:35 a.m, the patient complained of heartburn and bleeding from the vagina. At 03.00 a.m, patients were subject to close observation of the fetal heart rate and bleeding from the obgyn physician on guard. At 05.00 a.m, a stool or blood clot comes out of the vagina, but the general condition of the patient is still quite good. At 06.00 a.m a cardiotocography results was conducted, the results were still good. At 08.00 a.m complaints of pain have been reduced. At 09.30 a.m the patient experienced abdominal pain, but accompanied by chills. It was decided to do cesarean section cito. After surgery, the baby is born at 11:30 a.m with male sex, Apgar score 0, blooding (+), and stool cell (+). When a baby is born, the baby does not cry spontaneously, there is no movement. The baby looks blue and stiff. Suction is done on the baby's mouth and nose, which comes out is blood. Neonates resuscitation was performed, but the result was negative.

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3. Examination and Investigation At the initial examination when the patient first came, there were no signs of emergencies, other than placenta previa that had indeed been diagnosed from the hospital before the patient arrived. 4.

Diagnosis Based on anamnesis from patientâ&#x20AC;&#x2122;s illness can be diagnosed pre operatively. Pre-operative diagnosis is G3P1A1 + anemia + antepartum hemorrhagic. While, post-operative diagnosis is P2A1 premature intrauterine fetal death (IUFD) + placental abruption + uterine atony 5. Treatment and Course The diagnosis is made after caesarean section surgery. When it is found that the patient has uterine atony, drugs have been given to make the uterus contract. However, the patient's uterus also does not work as expected. The patient operator finally performed a subtotalis hysterectomy 6. Challenge Faced Atony uteri is an emergency condition that must be dealt with immediately. Late conditions can cause the patient to experience hypovolemic shock. This condition must be diagnosed and treated quickly. However, it is also necessary to pay attention to the parity of the patient and the patient's family. Woe if the patient does not have children or still wants to have children, but the patient's uterus is forced to do a hysterectomy, because it does not respond to the drugs that have been given. Not just drugs, but also compression that has been done, both internal and external.

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Figure 2. Uterine atony management algorithm in Indonesia

7. Recommendations After administration of drugs and compression, but to no avail. Based on the algorithm used in Indonesia, surgery must be carried out. Before that is done, there is one more way, namely the use of tamponade balloons. This is the earliest method of achieving the effect of tamponade to control postpartum bleeding. This method makes the uterus "work" in the case of uterine atony. Some previous studies show that this method is quite effective. Study conducted by Timor-Tritsch, IE., et al (2016), titled â&#x20AC;&#x153;A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy.â&#x20AC;? There were 3 spontaneous pregnancy and 7 cesarean sections.The average use of balloons is for 3 days. Tampon balloons can work successfully, minimally invasive and well-tolerated single treatment for cervical pregnancy and cesarean scar pregnancy. This simple treatment method has 4 main advantages: it effectively stops embryonic

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cardiac activity, prevents bleeding complications, does not require any additional invasive therapies, and is familiar to obstetricians-gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population. Another study with method done by Herrick, Tara., et al (2017). Entitled â&#x20AC;&#x153;A low-cost uterine balloon tamponade for management of postpartum hemorrhage: modeling the potential impact on maternal mortality and morbidity in sub-Saharan Africaâ&#x20AC;? shows that the use of balloon tamponade in clinics and hospitals can save 6547 lives (11% reduce maternal mortality), avoid 10,823 operations, and prevent severe anemia in 634 cases in Sub-Saharan Africa. Proven not if balloon tamponade costs a lot. A low-cost balloon tamponade has a strong potential to save lives and reduce morbidity. It can also potentially reduce costly downstream interventions for women who give birth in a health care facility. This technology may be especially useful for meeting global targets for reducing maternal mortality as identified in Sustainable Development Goal 3. se it is easy. Insert a rubber or silicon balloon into the uterine cavity and inflate the balloon with saline. There are so many variations of balloon tampons. In order of costs are the SengstakenBlakemore tube, the Bakri balloon, the Rusch balloon, Foley catheters and the condom catheter balloon.

Figure 3. Distal component of a tamponade balloon.

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Figure 4. Proximal component of a tamponade balloon.

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Table 1. Baloon tampon device

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Although there are so many variations of balloons that can produce a tampon effect, they are not the same design. All of these balloons have differences in the shape of the balloon, volume, and in terms of drainage of the uterine cavity. The shape of the balloon is not only different from one another, but also different shapes after being filled with water. Volume in producing tampon effects also differs from each literature. At present, only the Bakri Balloon is designed to treat postpartum bleeding. For other balloons, it can be used alone or used in combination with interventions, such as internal iliac artery ligase and B-lynch suture. Not only when there is expectation postpartum, but it can be used

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as prophylaxis in women who do have a high risk for experiencing postpartum bleeding. For example Rusch bal-loon. There is no definite hirearki about the time from the use of balloon tampons. Several studies have shown, if used immediately after vaginal birth, this will prevent the need for laparotomy. If it fails, it will not result in a very significant failure result, because it is easy to insert a tampon balloon. In addition, it will reduce the amount of bleeding while preparing for laparotomy surgery. If used earlier, there will be time for resuscitation in patients, such as blood type tests and the arrival of obstetricians. A study shows, the earlier a hysterectomy is performed, it will reduce the amount of blood that comes out, also reduces maternal mortality. In other words, the earlier use of tampon balloons will reduce maternal morbidity due to lack of blood. There are so many variations of balloon tampons (Table 1). There needs to be further assessment from the obstetrician regarding what type of balloon will be used, also the right time to use a tampon balloon. It is important to revise the guidelines for the management of postpartum bleeding in Indonesia. The use of balloon tampons can be used by general practitioners. Working according to guidelines will save the general practitioner from lawsuits. Also, it saves the hope of patients having more offspring.

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Reference 1. default - Stanford Children's Health [Internet]. Stanfordchildrens.org. 2019 [cited 1 October 2019]. Available from: https://www.stanfordchildrens.org/en/topic/default?id=postpartum-hemorrhage-90-P02486 2. Postpartum Hemorrhage: Background, Problem, Epidemiology [Internet]. Emedicine.medscape.com. 2019 [cited 1 October 2019]. Available from: https://emedicine.medscape.com/article/275038-overview 3. UpToDate [Internet]. Uptodate.com. 2019 [cited 1 October 2019]. Available from: https://www.uptodate.com/contents/overview-of-postpartum-hemorrhage 4. Chandraharan E, Krishna A. Diagnosis and management of postpartum haemorrhage. BMJ. 2017;:j3875. 5. WHO Recommendations on Prevention and Treatment of Postpartum Haemorrhage and the WOMAN Trial [Internet]. World Health Organization. 2019 [cited 1 October 2019]. Available from: https://www.who.int/reproductivehealth/topics/maternal_perinatal/pph-woman-trial/en/ 6. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(6):748-757. 7. Herrick T, Mvundura M, Burke T, Abu-Haydar E. A low-cost uterine balloon tamponade for management of postpartum hemorrhage: modeling the potential impact on maternal mortality and morbidity in sub-Saharan Africa. BMC Pregnancy and Childbirth. 2017;17(1). 8. Timor-Tritsch I, Monteagudo A, Bennett T, Foley C, Ramos J, Kaelin Agten A. A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy. American Journal of Obstetrics and Gynecology. 2016;215(3):351.e1-351.e8.

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â&#x20AC;&#x153;A CASE REPORT: DIRECT HYPERBILIRUBINEMIA IN 28-YEAR-OLD PATIENT WITH INTRAUTERINE FETAL DEATHâ&#x20AC;? Kristian Kenji K., Shafa Maulida, Wiranigitasari & Yusniya F. W. L. Faculty of Medicine, University of Brawijaya ABSTRACT A 28-year-old woman was referred to Saiful Anwar Hospital with a decreased of consciousness as the chief complaint. The decrease of consciousness has started since postpartum H1, which was one day before the admission at Saiful Anwar Hospital. She reportedly has a history of miscarriages in the first three months of pregnancy 11 years ago and a history of aterm labor 6 years ago. This case faced some challenges. The first challenge is the low rate of education in a rural community. The other challenge is due to incomplete of the health facility. Treatment of AFLP is by a combination of prompt delivery of the fetus, regardless of the gestational age and also maternal stabilization. Early administration of appropriate blood components, such as fresh frozen plasma, cryoprecipitate, RBCs, and platelets, may be needed. Recently, there is no standardized approach to diagnose this case, but based on the characteristic that is found may be used for diagnosis when clinical suspicion is present. After the diagnose is approached, the delivery of the fetus is paramount and the treatment is largely supportive care. Key Findings: Acute Fatty Liver Of Pregnancy, pregnancy, early diagnosis.

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A CASE REPORT: DIRECT HYPERBILIRUBINEMIA IN 28-YEAR-OLD PATIENT WITH INTRAUTERINE FETAL DEATH Kristian Kenji K., Shafa Maulida, Wiranigitasari & Yusniya F. W. L. Faculty of Medicine, University of Brawijaya AMSA Indonesia

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INTRODUCTION Acute fatty liver of pregnancy (AFLP), also known as “Acute yellow atrophy of the liver” is a rare condition that occurs in approximately one in 7,000 to one in 16,000 pregnancies. AFLP typically occurs in the third trimester. on rare occasions, AFLP presents as early as 22 weeks of gestation (2). However, it is often fatal to both mother and fetus that it is considered as a life-threatening condition since it is described as an idiopathic disorder with an extremely high percentage (10-85%) in mortality (7). There are no specific symptoms and no reliable examinations for AFLP, making an early diagnosis difficult (6). AFLP is characterized as a sudden onset of liver failure due to hepatic microvesicular steatosis. the mortality for both mother and neonate is extremely high but with early diagnosis and prompt treatment, outcomes and survival have improved. Multiple trauma usually presents challenging clinical scenarios with musculoskeletal injuries that are so this case needs immediate management. PATIENT’S HISTORY A 28-year-old woman was referred from a peripheral hospital with the chief complaint in decreased consciousness since postpartum H1 with no seizure. The day before administration, the woman gives birth during her ride to the Public Health Centre and had a miscarriage. The patient has a history of nausea, vomiting and positive icteric for 5 days before the admission. She had no complaints of defecation but the urination had decreased. The patient had a general appearance of severe ill and GCS number of 1-2-2, her pulse rate was 84 per minute and her respiratory rate was 24 per minute. She had icterus, pedal edema, and asymmetric movement of the lungs. Investigation revealed hemoglobin of 7,4 g/dl and white blood cells of 19,530/micro liter. Her liver function tests revealed aspartate aminotransferase 221 IU/l, alanine aminotransferase 159 IU/l, albumin 2,65 g/dL, total bilirubin 17,72 g/dL, direct bilirubin 14,52 mg/dL, indirect bilirubin 3,2 mg/dL, ureum 87,1 mg/dL, creatinine 3,59 mg/dL, and LDH 1528 U/L.The patient had jaundice, leukocytosis, an increase in AST and ALT, increased bilirubin, hypoalbuminemia, a decrease in fibrinogen, increase in D-dimer, azotemia, increase of K, decrease of Na and metabolic acidosis. A differential of AFLP and HELLP syndrome was made, and the miscarriage was suspected to be caused by Acute Fatty Liver of Pregnancy. INVESTIGATIONS AND EXAMINATION Based on physical examination, her heart rate (84 beats/minute) and respiration rate (24 times/minute) were higher than the normal limit. Her GCS scores were 1-2-2. Her vital sign was notable for a temperature of 36°C, her heart rate of 84 beats/minute, blood pressure of 116/56 mmHg, respiratory rate of 24. A lung examination was notable for asymmetric movement with Rh (-) and Ves (+). From laboratory examination, we revealed that the patient had normochromic normocytic anemia, leukocytosis, AST ↑↑, ALT ↑↑, Increased Bil TDI, Bil direct > Bil Indirect, ALP ↑, LDH ↑↑, FH ↑,

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azotemia, metabolic acidosis, Na â&#x2020;&#x201C;, K â&#x2020;&#x2018;. Urinary lysozyme: proteinuria (2+), nitrite (+), Leukocyte Esterase (LE) trace, blood (3+) and microscopic RBC predominantly dysmorphic.

Fig. 1 Blood serum enzyme test. From these data with clinical finding we conclude: Acute Fatty Liver Of Pregnancy (AFLP)

DIAGNOSIS Acute fatty liver of pregnancy (AFLP) is an uncommon but potentially fatal complication that occurs in the third trimester or early postpartum period to both the mother and the fetus, and one that can often recur in future pregnancies. AFLP is characterized by microvesicular fatty infiltration of hepatocytes without any inflammation or necrosis (5). Decreased levels of antithrombin and fibrinogen accompanied by laboratory evidence of DIC are present in most patients (11). Because AFLP is a rare disorder with significant maternal and fetal morbidity and mortality and with nonspecific clinical and laboratory findings, each patient with nausea, vomiting, malaise, and nonspecific symptoms in the third trimester of pregnancy should have a complete biochemical and hematologic workup.

TREATMENT AND COURSE Treatment of AFLP is by a combination of prompt delivery of the fetus, regardless of the gestational age and also maternal stabilization. Early administration of appropriate blood components, such as fresh frozen plasma, cryoprecipitate, RBCs, and platelets, may be needed (4). In this case, there is no standardized approach to diagnose this case, however, based on characteristics discovered from laboratory results, imaging, biopsy, and utilizing tools such as the Swansea criteria may be beneficial toward diagnosis while clinical suspicion is present. Following the diagnosis, the

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delivery of the fetus is paramount. Furthermore, if the patient's liver is fulminant due to AFLP, the frequency of liver recovers to normal is remarkably low. The aforementioned emphasizes the importance of early diagnosis (2). Toward patients with immediate postpartum state, acute liver failure besides encephalopathy, disseminated intravascular coagulation, acute renal failure, lastly gastrointestinal bleeding are the frequent life-threatening conditions linked with AFLP (2). The case's management system is based on 3 components, which are government, health facilities, and public community. The first component is the government. Parts of the government's programs concerning the reduction of maternal and child mortality are Badan Operasional Kesehatan (Health Operational Assistance) that has been launched by the Ministry of Health of Republic Indonesia to each Puskesmas (Public Health Center) since 2010 that is focused on preventive and promotive actions and Program Prencanaan Persalinan dan Pencegahan Komplikasi/P4K (Birth Delivery Planning and Complication Prevention). These programs will not operate properly without assistance from the other components. The second component is the health facilities. The quality and the number of health facilities should be enhanced continuously. In this case, both the child and mother were deceased because of the shortage of ventilator quantity in the ICU room. The treatment that should have been done immediately could not be done. The growth of the health quality should be done not only by class A medical facilities, but all classes of medical facilities too. Moreover, the proper communication within each medical specialist is required too. For instance, the practice of Telemedicine will make the patient's report addressed promptly and effectively that will encourage the doctors to determine the proper therapy. The third element is the public community. Reliable knowledge will make each group becomes more aware of their health that affects their medical check-up frequency during pregnancies.

CHALLENGES FACED This case faced some challenges. The first challenge is the low rate of education in a rural community, causing unawareness of their state of health, making them less likely to check on their health condition, and only came when the conditions had worsened to the state of it being an emergency. The other challenge is due to incomplete of a health facility. Based on this case, this patient dies due to lack of ventilator in ICU, on the other side, the hospital itself is facing a problem coping with the high number of emergency patients administered.

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DISCUSSION

Fig. 2 Pathogenesis of acute fatty liver of pregnancy (data are from Goel A, et al) Carbohydrate is the main source of living things. However, during the period of starvation, the metabolism track of carbohydrates will switch to lipid metabolism for the purposes of fulfilling the needs for energy. In the late period of pregnancy, the dietary intake of the mother is reduced while the energy expenditure increased due to the laboring process. On the other hand, it is also possible that the mother redirect dietary carbohydrates to enhance fetal nutrition. This condition leads to the diversion of the carbohydrates metabolism track to the lipid metabolism track. Thus, if the pregnant mother has some defect in metabolizing or utilizing her fat stores, she can be expected to become energy-deficient in late pregnancy. Acute Fatty Liver of Pregnancy has a characteristic of mitochondrial dysfunction in the liver that might lead to energy deficiency since mitochondrion is known as the power generator of the cell and the sites of fatty acid oxidation to produce ATP. The dysfunction itself is caused by the change of mitochondrial structure due to microvesicular steatosis. As the mitochondrial dysfunction widens in the liver, it may lead to liver failure known as mitochondrial hepatopathy. AFLP is a rare but catastrophic illness that occurs approximately one in 7,000 to one in 16,000 pregnancies. Although these cases now have been reduced to 12.5% compared with the early years of the 1980s (85%), it should still be aroused considerable attention that will cause high maternal mortality with severe complications. Early diagnosis and proper treatment are the cornerstones to decrease the mortality of AFLP. Ziki et al (9) reported that an 18â&#x20AC;&#x2030;year patient, in her first pregnancy at

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35 weeks gestation has died 3 days after admission and the diagnosis was confirmed on post-mortem and histology. Vora et al (10) A 24-year-old female at 34-week gestation, presented with malaise, nausea, vomiting, jaundice, and absent fetal movements. A clinical diagnosis of acute fatty liver of pregnancy was made. Although early cesarean section was performed, postoperative course was complicated by acute respiratory distress syndrome (ARDS) sepsis, and continuing coagulopathy. Supportive management in an intensive care unit resulted in a successful outcome. A clinical diagnosis of acute fatty liver of pregnancy was made on the 3rd day post-delivery. In our case the patient’s baby experience IUFD and several days later, the mother died too. CONCLUSION/RECOMMENDATIONS •

Medical practitioners, specifically doctors, should be able to encourage the patient to do general medical checkups such as blood serum test routinely, especially if the patient is gestating and if there is any clinical suspicion.

•

Communication between medical facilities should be improved to achieve better patient management.

•

Telemedicine utilization could be helpful to track patient's medical record so that the diagnosis could be easily determined

•

AFLP is a rare, life-threatening complication of the third trimester, the clinical presentation of AFLP is very variable and nonspecific. Immediate suspicion of the diagnosis, appropriate investigations, maximum supportive care and urgent initiation of therapy in an ICU should be highlighted to prevent poor outcomes

REFERENCES 1. LIU, Joy; GHAZIANI, Tara T.; WOLF, Jacqueline L. Acute fatty liver disease of pregnancy: updates in pathogenesis, diagnosis, and management. The American journal of gastroenterology, 2017, 112.6: 838. 2. HAN, Xu-Dong, et al. Case Report Analysis of seven consecutive cases of acute fatty liver of pregnancy: single center experience in China. Int J Clin Exp Med, 2017, 10.9: 13938-13943. 3. Kementrian Kesehatan Republik Indonesia. Untuk Menurunkan Angka Kematian Ibu dan Kematian

Bayi

Perlu

Kerja

Keras

[Internet].

Jakarta.

2010.

Available

from:

http://www.depkes.go.id/development/site/jkn/index.php?cid=793&id=untuk-menurunkanangka-kematian-ibu-dan-kematian-bayi-perlu-kerja-keras.html. 4. MAITTA, Robert W. (ed.). Immunologic Concepts in Transfusion Medicine. Elsevier Health Sciences, 2019. 5. Ko HH, Yoshida E. Acute fatty liver of pregnancy. Canadian Journal of Gastroenterology and Hepatology. 2006;20(1):25-30.

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6. Zhang YP, Kong WQ, Zhou SP, Gong YH, Zhou R. Acute fatty liver of pregnancy: a retrospective analysis of 56 cases. Chinese medical journal. 2016 May 20;129(10):1208. 7. Nelson DB, Yost NP, Cunningham FG. Acute fatty liver of pregnancy: clinical outcomes and expected duration of recovery. American journal of obstetrics and gynecology. 2013 Nov 1;209(5):456-e1. 8. GOEL, Ashish, et al. Pregnancy-related liver disorders. Journal of clinical and experimental hepatology, 2014, 4.2: 151-162. 9. ZIKI, Enesia, et al. Acute fatty liver of pregnancy: a case report. BMC pregnancy and childbirth, 2019, 19.1: 259. 10. Vora KS, Shah VR, Parikh GP. Acute fatty liver of pregnancy: a case report of an uncommon disease. Indian J Crit Care Med. 2009;13(1):34â&#x20AC;&#x201C;36. doi:10.4103/0972-5229.53115 11. Chaturvedi, S., & McCrae, K. R. (2019). Thrombocytopenia in Pregnancy. In Platelets (pp. 795-812). Academic Press.

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“A Case Report: Status Epilecticus and Loss of Consciousness in a Child with Human Immunodeficiency Virus (HIV) Suffering From Tuberculosis Meningoencephalitis and Cerebral Toxoplasmosis Co-Infection” 1

Nathanael Ibot David, 1John Thomas Rayhan Huwae, 1Dennis Ievan Hakim, 1Salsabila Elfirdausy 1

Faculty of Medicine, University of Brawijaya

ABSTRACT Patient’s History: A 6-year-old Indonesian girl was treated in Saiful Anwar General Hospital (SAGH) Malang with complaints of seizure followed by loss of consciousness. Episodes of seizure was observed at the referral hospital, Jombang General Hospital (JGH). Immediate treatment and management was given to the patient’s emergency condition. Challenges: It is known that patient lives in a broken household with unclear family history due her parents were abandoning her thus only being taken care of with her aunt and uncle who lives under poverty. Morever, patients were diagnosed by HIV lately with poor prognosis. Key Findings : The patient is diagnosed with stage 4 HIV at 5 years old with tuberculosis meningoencephalitis and cerebral toxoplasmosis. On December 2018, patient shows very low CD4+ T cells count (18 cells/μL) and abnormally high levels of both toxoplasma IgG and IgM. Patient was loss of conciousness, paralysis of left abducens nerve, right hemi-paralysis, and seizure. Treatment : The patient is brought to JGH outpatient department for regular check up on her treatment. The patient is treated with oral anti-tuberculosis (OAT), anti-retroviral (ARV) and therapy for toxoplasmosis. For over 6 months of observation, the patient takes her OAT, ARV and toxoplasmosis medication regularly and accordingly without showing any signs or symptoms regarding side effects of her medication. The patient is able to return to her daily life and continue her studies in the elementary school on Juny 2019. Neurologic improvement and increase in immune system, marked by returning physiological function and increase in CD4 count (>200 cells/µl), can be seen after 6 months of therapy.

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Author : Nathanael Ibot David, John Thomas Rayhan Huwae, Dennis Ievan Hakim, Salsabila Elfirdausy 3rd year medical student

ASIAN MEDICAL STUDENT’S ASSOCIATION – UNIVERSITY OF BRAWIJAYA

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A Case Report: Status Epilecticus and Loss of Consciousness in a Child with Human Immunodeficiency Virus (HIV) Suffering From Tuberculosis Meningoencephalitis and Cerebral Toxoplasmosis Co-Infection

Introduction Since being first discovered in 1982 by Centers for Disease Control (CDC), the distribution of Human Immunodeficiency Virus (HIV) has reached a global scale. According to World Health Organization (WHO), about 75 million people have been infected by HIV and 32 million of them died. Based on a study conducted by WHO in the South-East Asia region, out of the 110.000 children (ages 0-14 years old) suffering from HIV infection and only 44.400 receive treatment (WHO, 2017). It is known that 90% of pediatric HIV is caused by mother to child transmission. The chances of the virus being transmitted from the mother to infant is 5-20% by trans-placental means, 10-20% during childbirth and 5-20% during breastfeeding. Multiple clinical manifestations which appears are in the form of opportunistic infections such as Tuberculosis, fungal infections, persistent diarrhea caused by bacteria, pneumonia, invasive and uncommon parasitic infection, uncommon viral infections, and even sepsis (Muktiarti, 2014). Toxoplasmosis is a protozoa infection. It is the most often cause of cerebral lesions in HIV patients. Cerebral toxoplasmosis is a very lethal opportunistic infection if not diagnosed and treated as soon as possible since it can cause meningoencephalitis, cerebrospinal fluid disorder, hydrocephalus, microcephaly, chorioretinitis, seizures and deafness (Soedarmo et al, 2015). Cerebral toxoplasmosis produces multiple lesions, commonly located in the basal ganglia, cerebral cortex, brainstem and cerebellum. Diagnosis of toxoplasmosis can be confirmed by cranial CT scan or MRI, showing pathognomonic sign in the form of eccentric target sign Ěś ring formed lesion with calcification in its borders and edematous areas surrounding the lesion (MRI) (Kumar et al, 2010). Tuberculosis is the leading cause of death for patients infected by HIV. In the case of terminal stage HIV, the focus of infection of Mycobacterium tuberculosis moves hematogenously to other organs, hence known as extra-pulmonary Tuberculosis. This condition occurs when the CD4+ count reaches a level below 200 cells/Âľl. One of the forms of extra-pulmonary Tuberculosis which involves the brain is meningoencephalitis Tuberculosis. Based on research in the United States of America, the number of death of HIV patients with meningoencephalitis Tuberculosis is very high, reaching 67% of all cases. This shows its lethality as the life expectancy of HIV patients with meningoencephalitis Tuberculosis on treatment is only 9 months (Vinnan et al, 2009).

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Patient History A 6-years-old Indonesian girl was referred to the Emergency department of Saiful Anwar General Hospital (SAGH) Malang (referral center hospital of East Java) from Jombang General Hospital (JGH) (rural hospital) with episodes of seizure followed by loss of consciousness. Before being referred to SAGH, the patient underwent episodes of seizure for as many as 4 times with each episode being at least 5 minutes with clinical manifestations eyes rolling upwards and stiffness of both upper and lower extremity. The patient suffers from constant head ache 2 weeks before being brought to JGH followed by projectile vomiting 3 days before entering the hospital. After being treated for 3

Initial Physical Examination

(Upon entry to Saiful Anwar General Hospital, 12 December 2018)

General Condition:

Vital Signs:

Figure 2.1 Initial physical examination done in the emergency department

Anthropometry (aged 6years-old)

The patient appears to be Heart rate: 118 bpm sick, loss of consciousness.

Weight/age: 18 kg

Episode of seizure is still observed

Respiratory rate: 22x/min

Height/age: 113 cm

Temperature: 36.8Â°C

Head circumference: 49 cm

Blood pressure: 102/68 mmHg

Upper arm circumference: 17 cm

Oxygen saturation: 99% with Oxygen nasal cannula Ideal body weight: 20 kg running 2 litres/ minute % Ideal body weight: 93.2%

days in JGH, the patientâ&#x20AC;&#x2122;s aunt observed consistent asymmetrical eye movement, hemi-paralysis (right) was complained by the patient. Diarrhea was also observed.

Figure 2.2 A picture showing asymmetrical movement of the left eye

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From the age of 2 months, the patient was hospitalized frequently in Mojowarno Hospital with similar chief complaints diarrhea, cough, cold, apnoea, fever and pus-filled wounds on the head. However, the patient’s aunt does not know the diagnosis of the disease. At that time period, the patient is hospitalized at least once a month. After reaching 2-years-old, the patient rarely suffers from any sickness and has never been hospitalized until December 2018. The patient is raised by her aunt, a medical nurse on duty, ever since the patient was 2-months-old. Wary of her niece’s condition, the aunt initiated HIV screening to be done in JGH. The result came out to be HIV positive. However, since there were no complaints and with the patient’s condition improving (appears healthy, no delay in growth and development), no further treatment was taken. It is known that the patient lives in a broken household. The biological father of the patient died of unknown causes when the patient was 4-months-old and the biological mother ran away from home and her condition is not known.

69-years-old

46-years-old

68-years-old

41-years-old

40-years-old

Figure 2.3A pedigree diagram of the patient’s family tree

6-years-old

The history of pregnancy is unknown because the patient was cared for by the aunt and uncle of the patient since the age of 2 months. During pregnancy, the patient's mother and father lived in Kalimantan. The patient is born in a midwife’s private practice with a birth weight of 3400 grams, born spontaneously, adequate gestational age and spontaneous crying. Body length and head circumference during birth are unknown. The patient drinks formula milk from birth. Formula milk is given every ± 2-3 hours, with a volume of 40-50 cc. After being given milk the patient looks full and fell asleep. The patient uses soy milk because she was declared to be allergic to cow's milk at the age of 1 month by doctors in Kalimantan. According to the foster parents of the patient, she does not drink breast milk because the patient's mother does not want to breastfeed. Since the age of 6-12 months, the patient consumes milk porridge, twice a day and each portion is always finished. At the age of 10-12 months the patient is given soft rice mixture with a frequency of 2 times a day with each serving finished. One serving of

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the mixture contains rice with spinach / cassava leaves / carrot and chicken or egg. Since the age of 1 year the patient eats family food 2-3 times / day, with consumption of vegetables accompanied by tempeh or tofu and fruit is sometimes given in the form of papaya fruit. Side dishes of fish or meat are sometimes given 1-2 times / month if there is money. At present, the appetite of the patient according to her aunt is well and eats adequately. The patient’s immunization record according to the foster parents is good and can be seen in the table below

Age Vaccine

Birth

1 month

2 months

3 months

4 months

BCG

6 months

8 months

9 months

Figure 2.4 Immunization record

DPT Polio Hepatitis B Measles

Figure 2.5The patient’s house. A.The main road in front of the patient’s house;B.Front view of the patient’s house; C.Guest room; D.Family room and dining room; E.Patient’s bedroom; F.Bathroom

In Jombang General Hospital, efforts to treat the patient’s condition was done using antibiotics and anticonvulsants. The patient’s condition did not improve and she was referred to SaifulAnwar General Hospital with status epilepticus followed by loss of consciousness as the main issue. Upon arriving in the SAGH Emergency department, a quick physical examination was done and immediate treatment was given. The treatment consists of phenytoin (20mg x patient’s body weight in Kg) given intravenously for 30 minutes, followed by a prescription of phenytoin (8mg x

440

patient’s body weight in Kg) divided into 3 doses to be given daily and a dose of diazepam (0.3mg x patient’s body weight in Kg) for every episode of seizure. After the seizure was handled, further workup was requested in the form of compelete blood count, CT scan, lumbar punction, CD4 count and rapid test HIV. Figure 2.6 Laboratory findings Parameter

Sample (12/2/18)

Normal Value

8,8 g/dL

14,0-17,5 g/dL

Complete Blood Count Haemoglobin Leucocyte Haematocrit Thrombocyte

8000 /mm

4500-13000/mm 3

26,4 % 332.000/mm

38-42 % 3

67,5 fL

MCV

156.000-408.000/mm 3 80-96 fL

MCH

22,5 pg

28-33 pg

MCHC

33,3 g/dL

33-36g/dL

1,0 %

0-4%

Differential Count Eosnophil

0,3 %

0-1%

Neutrophil

64,6 %

51-67%

Lymphocyte

26,3 %

25-33%

7,8 %

2-5%

Sodium

130 mmol/L

135-147 mmol/L

Potassium

4,06 mmol/L

3,5-4,5 mmol/L

Chloride

97 mmol/L

98-106 mmol/L

Calcium

9,2 mg/dL

7,6-11,0 mg/dL

Phosphor

3,8 mg/dL

2,7-4,5

14 U/L

0-40

Basophil

Monocyte Blood Chemistry

SGOT

7 U/L

0-41

77 mg/dL

<200 mg/dL

Ureum

8,9 mg/dL

16,6 – 48,5

Creatinin

0,25 mg/dL

<1,2

0,03

Risk of Infection : > 0,5

SGPT Random Blood Glucose

Procalcitonin Rapid test (1,2,3)

Reactive 18 cells/ µL

CD4 IgG anti CMV

302

positive: >1,0 IU/mL

IgM anti CMV

0,182

positive: >1,0 IU/mL

IgG anti Rubella

66,29

positive: >10 IU/mL

IgM anti Rubella

0,271

positive: >1,0 IU/mL

IgG anti Toxoplasma

>650

positive: >3 IU/mL

IgM anti Toxoplasma

19,2

positive: >1,0 IU/mL

The result of complete blood count shows slight abnormality in hemoglobin level (8.8g/dL). Differential count reveals high number of monocytes (7.8%). The blood chemistry indicates hyponatremia (30mmol/L) and slightly low amount of ureum (8.9mg/dL). HIV rapid test indicates reactivity in all 3 tests, which means that the patient is HIV positive. CD4 count is very low (18

441

cells/ÂľL). Abnormally high levels of both toxoplasma IgG and IgM is found indicating present infection of toxoplasma. Figure 2.7 Analysis on the CSF obtained by lumbar punction

Figure 2.8 Cranial CT scan

The CT scan shows ring enhancing cystic lesion, thin wall, in the subcortical lobe of the right frontal and parietal lobe (size 0.8x0.8x0.8 cm) and multiple in the subcortical lobe of the left temporoparietal lobe (the largest size is 2.6X4.2X3.1cm in the left parietal lobe) accompanied by extensive peripheral edema that forces the left lateral ventricle and causes a midline shift as far as

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0.9cm to the right, cerebral toxoplasmosis and Tuberculosis is suspected. Another enhancing solid lesion of 0.8x0.8x0.8cm in the left cerebellum with minimal perifocal edema is spotted. After the emergency condition was handled, the patient was hospitalized in the Pediatric High Care Unit (HCU) with a diagnosis of stage 4 HIV followed by Tuberculosis meningoencephalitis and cerebral toxoplasmosis co-infection. The patient receives the management of TB meningoencephalitis in the form of intramuscular injection of streptomycin 20mg/kg/day for 2 months, followed by oral intensive FDC for 2 months and continued phase FDC therapy for 10 months, etambutol 20mg /kg/day for 2 months, oral prednisone 2mg/kg/day for 4 weeks and oral pyridoxine with a dose of 1 tablet a day. For the management of cerebral toxoplasmosis, patients receives treatment in the form of oral clindamycin 20mg/kg/day and oral pyrimethamine 1mg/kg/day for 6 months. Patients start receiving first-line ARVs 2 months after the treatment of TB meningoencephalitis (March 2019) until now. The ARVs given were zidovudin, lamivudin and nevirapine.

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Examination

Description

Description Decreased awareness, adequate sponatneous breathing, no shortness of breath, not pale, not General Conditon cyanotic awareness, adequate sponatneous breathing, no shortness of breath, not pale, not Decreased General Conditon cyanotic Examination

Vital Signs

GCS 345; pulse 118 beats / minute, palpably strong, regular; respiratory rate 22 times / minute,

Vital Signs

GCS 345; pulseadequate; 118 beats axillary / minute, palpably strong, regular; respiratory 22 times spontaneous, temperature of 36.8Â°C; blood pressure rate 102/68 mmHg/ minute, spontaneous, adequate; axillary temperature of 36.8Â°C; blood pressure 102/68 mmHg

Head Head

Normocephalic; black easily pulled out; signs of trauma (-) Face : symmetrical; oldhair, mannot face not observed Face : symmetrical; old man face not observed Eye : Asymmetrical eyeball movement, it appears that the left eyeball cannot move to the right Eye : Asymmetrical eyeball movement, it appears that the left eyeball cannot move to the right side optimally; not exophthalmus; conjunctiva is not anemic; sclera is not jaundice; isochorous side optimally; not exophthalmus; conjunctiva is not anemic; sclera is not jaundice; isochorous round pupils, 3mm / 3mm diameter, good light reflexes round pupils, 3mm / 3mm diameter, good light reflexes Nose :: Nasal Nasal septum septum is is symmetrical, symmetrical, nasal nasal cavum cavum is is not not hyperemic, hyperemic, there there is is no no nasal nasal tip tip Nose breathing, no visible secretions coming out of the nostrils breathing, no visible secretions coming out of the nostrils Ears :: Serumen Serumen is is not not observed observed on on both both dextra dextra and and sinistra sinistra ears. ears. Tympanic Tympanic membrane membrane intact intact in in Ears both ears both ears Mouth : Lips appear red, oral mucous appears wet, no enlargement of tonsils T1/T1, spreading crypte or detritus is not observed

Normocephalic; black hair, not easily pulled out; signs of trauma (-)

Neck Neck

Stiffness Stiffness of of the the neck neck is is detected, detected, lymph lymph node node enlargement enlargement was was not not detected detected during during palpation palpation Symmetrical; Symmetrical; no no chest chest shape shape was was obtained obtained from from the the excavate excavate pectus pectus or or carcinate carcinate pectus, pectus, no no visible visible subcostal, subcostal, intercostal intercostal and and suprasternal suprasternal retractions; retractions; no no xylophone xylophone ribs ribs were were visible; visible; ictus ictus cord not visible, ictus cordis is palpable between the 4th and 5th ribs in the left midclavicular cord not visible, ictus cordis is palpable between the 4th and 5th ribs in the left midclavicular line ; sonor sound was heard during percussion line ; sonor sound was heard during percussion Lung: normal fremitus, sonor percussion, vesicular breath sounds, no soft wet crackles, no Lung: normal fremitus, sonor percussion, vesicular breath sounds, no soft wet crackles, no wheezing wheezing Heart: ictus cordis is palpable between the 4th and 5th ribs in the left midclavicular, no murmur Heart: ictus cordis or gallop was heardis palpable between the 4th and 5th ribs in the left midclavicular, no murmur

Thorax

or gallop was heard

Abdomen

Inspection: flat, umbilicus is not protruding, collateral veins are not visible. Inspection: flat, umbilicus is sounds not protruding, collateral veins are not visible. Auscultation: normal bowel Auscultation: normal bowel sounds Percussion: tympanic sounds was heard Percussion:turgor tympanic soundssoefl; was heard Palpation: is enough, Hepar and Lien are not palpable

Palpation: turgor is enough, soefl; Hepar and Lien are not palpable Extremities

Extremities

Warm palpable extremities; capillary refill time 1 second Not anemic, no jaundice, edema or cyanosis Warm palpable extremities; capillary refill time 1 second

Urogenital

Pubic hair was seen edema or cyanosis Not anemic, nonot jaundice,

Anus Urogenital

Normal Pubic hair was not seen

Skin Anus

Dermaatosis was not observed Normal

Skin

Consciousness: Dermaatosis wasGCS not345 observed No seizure. Meningeal sign: stiff neck (+), brudzinki I,II (+). Paralysis of left 6th cranial nerve

Consciousness: GCS 345 No seizure. Meningeal sign: stiff neck (+), brudzinki I,II (+). Paralysis of left 6th cranial nerve

Neurologic State

Arms Right Physiological reflex Pathological reflex Motoric function Sensoric function

Left

Legs Right

Left

Increased Increased Increased Increased Positive

Positive

Normal

Figure 2.9 General condition in the HCU ward.

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After 12 days of treatment the patient was discharged an outpatient treatment is done where the patient returns to the outpatient department every month for monthly check-up regarding the patient’s condition (TB meningoencephalitis, cerebral toxoplasmosis and HIV). The table below shows the patient’s progress 6 months after being hospitalized in SAGH. Surveillance

Dec-18

Jan-19

Feb-19

Mar-19

Apr-19

May-19

Jun-19

Loss of Conciousness

(+)

(-)

Paralysis of Left Abducens Nerve

(+)

(-)

Right Hemiparalysis

(+)

Weak upper extremity, paralysis of lower extremity

Seizure Vomiting

(+) (-)

(-) (-)

Weight (Kg)

17.5

Height (cm)

113

114.5

115

116

Ideal Weight (Kg)

% Ideal Weight

93.2

100

Upper Arm Circumference (cm)

17.5

Head Circumference (cm)

118

102

104

103

100

102

100

37.8

36.5

36.9

36.6

36.7

Clinical

Active upper Active upper Active upper Active upper extremity, extremity, extremity, extremity, Active upper paralysis of paralysis of paralysis of paralysis of extremity, lower lower lower lower active lower extremity extremity extremity extremity, extremity (improvement) (improvement) (improvement) walking (+) , running (+) , running (+) , running (+)

Growth

Vital Signs Heart Rate (bpm) Respiratory Rate (x/min) Temperature (°C)

Neurological Function Upper Right Extremity Lower Right Extremity

Laboratorium Findings Hb Leucocyte count

8.8 8000

445

9.2

9.5

2770

4270

Height (cm)

113

114.5

115

116

Ideal Weight (Kg)

% Ideal Weight

93.2

100

Upper Arm Circumference (cm)

17.5

Head Circumference (cm)

118

102

104

103

100

102

100

37.8

36.5

36.9

36.6

36.7

Vital Signs Heart Rate (bpm) Respiratory Rate (x/min) Temperature (°C)

Neurological Function Upper Right Extremity Lower Right Extremity

Laboratorium Findings Hb Leucocyte count HCT Thrombocyte count SGOT SGPT Random Blood Glucose Check Procalcitonin Sodium Potassium Chloride Calcium Phosphor CD4 IgG anti CMV IgM anti CMV IgG anti Rubella IgM anti Rubella IgG anti Toxoplasma IgM anit Toxoplasma

8.8

9.2

9.5

8000

2770

4270

26.4

27.2

332000

237000

214000

14 7

32 11

25 7

103

0.03 130 4.06 97 9.2 38 18 302 0.182

0.02

232

66.29 0.271 >650

>650

19.2

0.317

Figure 2.10 Table showing the patient’s progress 6 months after being hospitalized in December 2018

446

Therapy

Dec-18

Jan-19

Feb-19

Mar-19

Apr-19 May-19

Jun-19

IM streptomycin po. FDC pediatric intensive fase po. FDC pediatric continual fase po. Etambutol po. Prednisone po. Clindamicin po. Pirimetamin po. Folic acid po. Vitamin B6 po. Cotrimoxazole po. Zidovudin po. Lamivudin po. Nevirapine

Figure 2.11 The table shows the medication taken by the patient for 6 months after being hospitalized in SAGH Diagnosis 1. Status Epilepticus et causa Meningoencephalitis Tuberculosis 2. Meningoencephalitis Tuberculosis 3. Toxoplasma Cerebral 4. Electrolite Imbalance et causa a. Syndrome of Inappropriate Antidiuretic Hormone Secretion b. Cerebral Salt Wasting Discussion In this case, an eight year old girl, weighing 18 kilograms, came with status epilecticus accompanied with consciousness disorder as the main complaint. Before coming to Saiful Anwar General Hospitalâ&#x20AC;&#x2122;s (SAGH) Department of Emergency, patient has experienced seizure episode 4 times. The duration of each seizure episode goes for approximately 5 minutes and after the episode concludes, the patient goes lethargic and hard to wake up with excessive sleeping. Moreover, it is known from the aunt of the patient that the patient has been experiencing prolonged headaches before being admitted to SAGHâ&#x20AC;&#x2122;s Department of Emergency. In consciousness check using the Glasgow Coma Scale method, we found these results; 3 for eye response, 5 for motor response, 4 for verbal response, totaling 12 points (moderate). Adding to the list of complaints, the patient also experiences diarrhea, projectile vomiting, and refuses to eat. Through this case, the patient is being suspected of central nervous system disorders, based on the patientâ&#x20AC;&#x2122;s complaint of headaches accompanied with projectile vomiting.

447

During the management of the patient in SAGH’s Department of Emergency, the physician conducts anamnesis with the patient’s aunt and found out that the patient is frequently sick during 2 years of age with various complaints, being, diarrhea, cold, apnea, fever, and lacerations with pus appearance on the head region. Other findings shown that every visit that the patient took to the hospital is presented the same complaints. Through this condition, the physician suspects HIV as an underlying cause of the symptoms and complaints, knowing this, SAGH’s Department of Emergency consults this case to the Department of Paediatrics for the patient to undergo HIV testing. Based on the results of the tests done by the Department of Paediatrics, it is now a fact that the patient has HIV. Based on that finding, SAGH’s Department of Emergency suggests for the patient to undergo CT scan, complete blood tests, lumbar puncture, and chest X-ray. After the lab results came out, readings and interpretation of the results were conducted. From the results of the CT scan, it is found that there is a solid lesion with the dimensions of 0,8x0,8x0,8 centimeters in the left cerebellum with minimal perifocal edema. Other than the finding of a solid lesion, a hyperdense appearance on the basis cranii of the patient is found. Based on the X-ray results, there is no appearance of TB lesions on the patients lungs. According to the blood tests, it is found that there is an increase in monocyte cell count to 7.8%, a decrease in sodium and chloride levels. Based on the CSF analysis, there is an increase in protein, a decrease in glucose levels, accompanied with the increase in LDH levels. Mononuclear cells are found within the CSF as much as 92%. Based on the complaints and the laboratory examinations, the patient is suspected as having a TB meningoencephalitis. Encephalitis is characterized by a condition with a decrease in consciousness, generalized seizure, and episodes of headaches. The degree of encephalitis varies, and it is know that it can undergo progressivity during a few months, causing death. Especially in immunocompromised patients, such as patients with HIV, the manifestations of encephalitis will undergo progressivity until 8 weeks. Using lab interpretations, encephalitis is described by pleocytosis of mononuclear cells, an increase on protein levels, and normal or low glucose levels in CSF post lumbar puncture (Avindra, 2003). Based on the classification of tuberculosis itself, it is known that meningoencephalitis TB is the most severe and life threatening. Some of the most usually encountered complaints on patients experiencing meningoencephalitis TB are headaches, neck rigidity, accompanied with projectile vomiting as the effects of intracranial processes. Those intracranial processes results ranging in neurological deficits to coma. In this case, the patient complained about episodic seizures accompanied with lethargy, excessive sleeping, and difficulty in being woken up from sleep after the episode subsides. The decrease in consciousness is caused by brain damage, affecting the consciousness of the patient (Yasar, 2011).

448

Based on the pathogenesis of meningoencephalitis TB, the initial focus of infection originates first from the lungs. Meningoencephalitis TB is a hematogenous spread of lung TB where it causes disorders in the brain function. As its physiological functions dictate, consciousness is being affected by 2 important functions, which is the brain cortex and the function of ARAS (Ascending Reticular Activating System) that is always activated as a standby mode. Brain disorders caused by meningoencephalitis TB impacts the functions of the brain cortex and the ARAS systems. Those problems results in consciousness disorders on a person (Rock, 2008). Based on this case, it is reported that there is episodic seizures with decreased consciousness. This could be concluded as the manifestations of brain disorders caused by meningoencephalitis TB as in previous discussion. The damage done by meningoencephalitis TB could also be caused by other infections targeting the CNS, especially the brain, one of them being toxoplasmosis. In this very case, the patient is experiencing both meningoencephalitis TB and cerebral toxoplasmosis. Toxoplasma Cerebral Toxoplasmosis is the commonest central nervous system findings on HIV patients thus becoming one of its complications. Toxoplasmosis is caused by Toxoplasma gondii, an intracellular obligate parasite, which is able to cause severe opportunistic infection on HIV patients. In an immunocompromised condition, toxoplasma will reactivate when the CD4 count is under 200 cells/ml. In more severe condition, namely 200 cells/ml, toxoplasma has a high risk to cause cerebral toxoplasmosis. The common finding on this condition is extremely high anti toxoplasma IgG titer. (Ibebuike et al, 2012; Espinoza-oliva et al, 2016). Epidemiology Seropositive toxoplasma on healthy americans ranged from 10% until 40%. These findings are higher in Europe and Central America, namely 70% until 90%. Overall, cerebral toxoplasmosis incidence is decreasing due to better use inprophylaxis and treatment of HIV (anti retroviral) (Avindra & Anthony, 2003). Etiology Toxoplasmosis is caused by Toxoplasma gondii, an obligate intracellular parasite which is found for the first time on African Gondii mouse. Cat is the definitive host of Toxoplasma due to its cycle which can only be completed inside the cat gut (Avinra & Anthony, 2003).

449

Picture 3.3 Life Cycle of Toxoplasma gondii. Cat is the definitive host of Toxoplasma gondii due to its cycle which can only be completed inside the cat gut.

Pathophysiology The mechanism of which HIV enter inside the brain remains unclear but novel researchs stated that infected cells could bind to vascular and enter through the blood brain barrier via blood. The viruses thus being transmitted to microglial or perivascular macrophage. Virus then will replicate and infect another microglia and spread the infection. Infected microglials will release cytokines which enchance apoptosis. The result of this cascade is encephalitis (Bowen et al, 2016).

450

Picture 3.4. Neuropathophysiology of HIV Infection inside the Brain

Cerebral toxoplasmosis is often caused by reactivation of recent chronic infection. Changing of cytokines inside the brain cells will enhance the differentiation of cyst to be tachyzoite. Toxoplasma gondii could replicate in all kind of brain cells and proliferation of this parasite depends to host immune response. Novel research showed that CD4 T cells and Interferon Gamma in charge of cyst proliferation inside the brain cells. In some infected individuals, immune response failed in eradicating infection thus the parasite became dormant and developed chronic infections. Because of this explanation, individuals who own low CD4+ T cells count such as HIV patients will trigger a severe toxoplasmosis, such as cerebral toxoplasmosis which is life-threatening (Boothroyd, 1998).

Clinical manifestation Toxoplasmosis on HIV patients will manifest as an encephalitis, chorioretinitis, or pneumonitis depending on hostâ&#x20AC;&#x2122;s immune. Cerebral toxoplasmosis has subacute onset which is initiated with symptomps such as fever, headache, and loss of conciousness. Cerebellar, subcortical and cortical lesion on more than half cases cause neurological symptoms such as hemiparesis, ambulatory gait, and language impairement. Loss of cociousness, headache, cognitive impairement, and seizure are the most common clinical manifestations on cerebral toxoplasmosis patients (Ganiem et al, 2013). Cerebral Abcess

451

Cerebral abcess is one of the most common clinical manifestation of cerebral toxoplasmosis on HIV patients. Symptomps can be seen in weeks and CT scan shows cerebral abcess with predilection in ganglia basalis this triggers motor disorder such as hemichroea, parkinsonism, and tremor. Multiple abcess is often seen on HIV patients with toxoplasmosis thus causing vision impairement, focal seizure, afacia, hemiparesis or hemisensory, cranial nerves paralysis, and cerebellum dysfunction (Avindra & Antony, 2003). Encephalitis Encephalitis is marked with loss of conciousness, generalized seizure, and headache. CT scan shows normal findings in the beginning. The degree of encephalitis variate and could progress in months thus causing death in second weeks of disease history. HIV patients which is also suffering of diffuse encephalitis will experience progresivity until 8 weeks. Toxoplasmosis will affect and invade lymph node, heart, muscle, lungs, bone marrow, and brain thus causing systemic disease. Cerebrospinal fluid shows pleiocytotic of mononuclear cells with an increase in protein and glucose (Avindra & Anthony, 2003). Diagnosis Presumtive diagnosis of cerebral toxoplasmosis can be made with clinical, radiological, and serological test. Clinical diagnosis can be made when individual with HIV infection shows CD4 cells below 100 cells/ml with neurological symptomps. Generally, response to success therapy will shows improvement after empirical treatment for 2-3 weeks. Serological diagnosis shows an increase in IgG antitoxoplasma for 1-2 weeks post infection and reach its peak in 6-8 weeks. After that It will decrease in 1-2 years but could persist on some individuals. Radiological diagnosis is based on CT scan or head MRI with a hipodense lesion, ring enhancement, and perilesion edema. Most of nodule are found near basal ganglia. But, lesion could be found in cerebellum, brain stem, and medulla spinalis. PCR can be used to clarify the diagnosis. Immunoglobulin M for antitoxoplasma findings shows a novel infection, meanwhile immunoglobulin G finding shows reactivation of toxoplasmosis. (Wright et al, 2018; Valadkhani et al, 2017). Table 3.16 Antibody

Interpretation of Antitoxoplasma

452

Gambar 3.5 MRI of Toxoplasma Cerebral Differential Diagnosis In immunocompromised individuals, differential diagnosis of cerebral toxoplasma could be lymphoma, progressive multifocal leukoencephalopathy, cerebral infract, and zooster varicella. Treatment Treatment of toxoplasmosis on HIV patients follows this algorithm :

453

The occuring of abducens nerve paralysis is caused by the increase in intracranial pressure, which is proved by the increase in CSF amount. The increase in intracranial pressure is a byproduct of the increase of the rate of CSF production and amount which will induce disorders by compressing the ligamentum petrosa which will disrupt the abducens nerve and cause symptoms (Murthy, 2005). Based on studies, it is known that in TB infections both in active condition and old lesions there are disorders in the cranial nerves. The predilection of the cranial nerve disorders involves the third nerve (Oculomotorius), sixth (Abducens), and seventh (Facialis). According to the present condition of the patient after being infected by meningoencephalitis TB, there is a disorder involving the reduced lateral movement of the eyeball which suggests problems in the sixth cranial nerve (Abducens) (Jeroma, 2014).

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The condition of electrolyte imbalance in patients with meningoencephalitis TB is strongly suspected as the output of various causes. From multiple sources, it is said that there is a regulation disorder caused by the reduced function of the adrenal cortex. Other than that, disorders in the electrolyte balance could also be caused by food intake disorders and projectile vomiting which is commonly happening in children (Kasper, 2018). Electrolyte imbalance is defined as an imbalance in the electrolyte levels, marked by the increase or decrease of the electrolyte levels inseide the body caused by a certain metabolic process inside the body. This could be caused by many causes, one of them being the loss of body fluids du to vomiting, diarrhea, dan burns. Other than those, renal disorders and metabolic disorders could also be a possible cause. Based on this case, the electrolyte disorder is possibly caused by 2 possible causes, which is Cerebral Salt Wasting Syndrome (CSWS) and Syndrome of Inappropriate Antidiuretic Hormone (SIADH) (Audibert,2012). Cerebral Salt Wasting is a possible cause of hyponatremia in CNS disorders. Cerebral Salt Wasting is characterized by hyponatremia accompanied with the increase of urine sodium levels and hypovolemia. CSW mostly appears after a CNS disorder, such as subarachnoid hemorrhage. Some researches mentioned that CSW could happen because of the secretion of Brain Natriuretic Peptide (BNP) after brain damage which enters the systemic circulation, facilitated by the disruption of the blood brain barrier. BNP works at the collecting ducts on obstructing the reabsorption of sodium and renin secretion, explaining the symptoms happening in this patient (Cerda, 2008). The other diagnosis which could facilitate this condition is Syndrome of Inappropriate Antidiuretic Hormone (SIADH). In the case of SIADH, there is an increase in the amount of antidiuretic hromone that works on the aquaporins in the collecting ducts, causing an increase in the extracellular volume inside the body which leads to hypervolemia and urine volume decrease. SIADH needs to be differentiated from CSW in respect to the major differences in treating these disorders. In the case of CSW, there is a need of fluid resucitation and sodium supplementation. Conversely, in SIADH, there needs to be a fluid restriction imposed on the patient (Cuesta, 2016). Treatment Based on the discussion above, to manage the emergency condition being status epilecticus accompanied with decrease of consciousness, there needs to be management being : 1. Phenitoin (IV) 20mg/kgBW as long as 30 minutes, continued 8mg/kgBW divided into 3 doses 2. Diazepam (IV) 0.3mg/kgBW

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After the emergency management is done, there needs to be management of HIV. Based on the planning, there needs to be 2 types of management being: 1. Management of HIV (Based on the case being 4th stadium HIV) 2. Management of opportunistic infections a)

Meningoencephalitis TB

Cerebral toxoplasmosis

1. HIV management There needs to be prophylaxis initiation by using cotrimoxazole in order to prevent the infection of Pneumocystis jiroveci (PCP) in the patient. The treatment using prophylaxis is according to the WHO guideline in 2013 being that children below 5 years old needs to be given cotrimoxazole in any stadium and CD4+ count below 350 cells/ml that could be continued throughout life or stopped if CD4+ count is above 350 cell/ml (Kemenkes, 2014). Other than the diagnosis of HIV, there needs to be consideration to search for opportunistic infections. If an opportunistic infection is found, the opportunistic infection needs to be first treated before the use of ARVs. Based on the guideline from the Ministry of Health, the first line treatment of ARVs recommended are 2 Nucleoside Reverse Transcriptase Inhibitor (NRTI) + 1 Non Nucleoside Reverse Transcriptase Inhibitor (NNRTI). The first category of NRTIs used are lamifudin. Lamifudin could be combined with other NRTIs, jidovudin and one other NNRTI, nevirapin. In this patient, the physician decided to administer sidovudin (AZT), lamifudin (3TC), dan nevirapin (NVP). 2. Management of opportunistic infection a)

Meningoencephalitis TB Because it is know that the patient has meningoencephalitis TB, the patient needs to be given anti tuberculosis drugs before the management of HIV being the administration of ARVs. Based on the guideline from CDC, it is said that the effective period of ARV administration on TB cases are 4-8 weeks long after the initial administration of anti tuberculosis drugs. This is needed to prevent the happening of Immune Reconstruction Inflammatory Syndrome (IRIS). Anti tuberculosis drugs used in management of tuberculosis is being divided into 2 phases, those 2 phases being the initial and late phase. There exists 5

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medications in the management of TB, which are rifampicin (R), isoniazid (H), pyrazinamid (Z), etambutol â&#x201A;Ź, dan streptomycin (S). In the initial phase, during 2 months, the RHZE drugs are used. During the late phase, the RH drugs are used during 10 months. Prednison is administered in order to prevent fibrosis in the lung tissue post TB infection. b)

Cerebral toxoplasmosis In order to manage toxoplasmosis, the physician administered clindamycin and pyrimethamine. The duration of therapy in TC in HIV patients varies from the minimal duration of 3 weeks until 6-8 weeks. The challenge in the management of TX is the chemotherapy target in order to suppress the growth of tachyzoids, but having a limited effect in suppressing the growth of bradyzoids. Knowing that, prophylactic therapy in immunocompromised individuals are needed to prevent relapse. Pyrimethamine is a medication used in toxoplasmosis with a side effect in the spine bone marrow. Folic acid is used In combination with pyrimethamine to prevent bone marrow depression

Conclusion Currently the patient is being treated with anti tuberculosis drugs, ARVs, dan toxoplasmosis therapy. According to the Peds-QL examination, the patientâ&#x20AC;&#x2122;s growth arent experiencing a decrease in quality. Family views on the disease and treatment taken by the patient in the long term is very important in the patientâ&#x20AC;&#x2122;s physical and mental growth. During the 6 months long observation, the patient obeys the instructions to take ARVs, anti tuberculosis and toxoplasmosis. Any complaints regarding side effects of the drugs were not found. The patient is capable of doing everyday activities and continuing education. From the 6th month therapy evaluation, any signs of side effects were not found and marked increase of immunity, proved by the CD4+ cell count above 200 cells/microlitre.

Daftar Pustaka Avindra Nath., Anthony P. Sinai. 2003. Cerebral Toxoplasmosis. Current Treatment Options in Neurology, 5:3-12. Yasar, K.K., Pehlivanoglu, F., Sengoz, G., Ince, E.R. and Sandikci, S., 2011. Tuberculous meningoencephalitis with severe neurological sequel in an immigrant child. Journal of neurosciences in rural practice, 2(1), p.77. Rock, R.B., Olin, M., Baker, C.A., Molitor, T.W. and Peterson, P.K., 2008. Central nervous system tuberculosis: pathogenesis and clinical aspects. Clinical microbiology reviews, 21(2), pp.243261.

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Murthy, J.M.K., 2005. Management of intracranial pressure in tuberculous meningitis. Neurocritical care, 2(3), pp.306-312. Jerome H. Chin. 2014. Tuberculous meningitis : diagnostic and therapeutic challenges, American Academy of Neurology Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. Harrison's principles of internal medicine. McGraw-Hill Professional Publishing; 2018. Audibert, G., Hoche, J., Baumann, A. and Mertes, P.M., 2012, June. Water and electrolytes disorders after brain injury: mechanism and treatment. In Annales francaises d'anesthesie et de reanimation (Vol. 31, No. 6, pp. e109-15). Cerdà-Esteve, M., Cuadrado-Godia, E., Chillaron, J.J., Pont-Sunyer, C., Cucurella, G., Fernández, M., Goday, A., Cano-Pérez, J.F., Rodríguez-Campello, A. and Roquer, J., 2008. Cerebral salt wasting syndrome. European Journal of Internal Medicine, 19(4), pp.249-254. Cuesta, M. and Thompson, C.J., 2016. The syndrome of inappropriate antidiuresis (SIAD). Best Practice & Research Clinical Endocrinology & Metabolism, 30(2), pp.175-187.

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