The effect of hyaluronic acid on the changes in Matrix Metalloproteinase-1 (MMP-1), leukocytes level, and bacteriocide effects among patients with Wagner 3 and 4 diabetic foot ulcer

Background: Diabetes Mellitus (DM) has become a major public health problem. A significant complication of Diabetes Mellitus is the emergence of diabetic foot ulcers that require special treatment in healing. Hyaluronic Acid plays a role in cell proliferation and cell movement and is needed in the process of wound healing. The main goal of treatment of diabetic ulcers in the foot is to achieve wound closure as quickly as possible, prevent recurrence and amputation.

Methods: A true experimental study with pre and post-test design has been conducted among 32 diabetic foot patients at Sanglah General Hospital which divided into 2 groups: Hyaluronic acid and NaCl 0.9% using consecutive techniques. The hyaluronic acid compared to NaCl 0.9% on MMP-1, leukocyte levels, and bacteriocide effects in patients with Wagner's diabetic foot 3 and 4 were assessed. Data were analyzed using SPSS version 20 software for Windows.

Results: The results showed that Hyaluronic Acid increased MMP-1 levels while NaCl 0.9% reduced MMP-1 levels significantly (P<0.05). Hyaluronic Acid was able to reduce leukocyte level significantly compared to NaCl 0.9% (P=0.006). A positive bacterial culture was also found markedly lesser in Hyaluronic Acid groups compared with NaCl 0.9% (P<0.001). Multivariate analysis using logistic and linear regression also showed significant differences in the MMP-1 and leukocyte level (P<0.001) and positive culture results using hyaluronic acids (OR: 0.020; 95% CI 0.003-0.166; P<0.001)

Water Sport-Related Spine Injury in Bali: A Review and Preliminary Study

Background: Spinal Injury is a devastating injury with life-long impact on an individual’s health and quality of life. Sport­ing activities, such as water sport, is also known contributed to the spinal injury.  This study aims to evaluate the water sport-related spine injury (WS-RSI) which is occurred in Bali during 2017 as a preliminary study at BROS Hospital.

Methods: A cross-sectional study was conducted retrospectively among 55 patients who got an injury during water-sport activity in 2017 and admitted to BROS Hospital, Denpasar, Bali by medical records. There was 28 patient-related spine injury. Demographic status regarding age, sex, length of stays, hemoglobin (Hb), random blood glucose, nationality, country origin, treatment, patient’s status, history of alcohol intake, type of water sport, and the location of spine injury were recorded. Data were analyzed using SPSS version 25 for Windows in mean±SD, percentage, and odds ratio (OR) as well as statistically significant if P-value less than 0.05.

Results: Indonesian travelers were predominant in WS-RSI (53.6%), followed by China and Australia (17.9%), India, Japan, and European countries (3.6%, respectively). The average age of patients was higher in spine injury (47.89±15.98 years; P=0.047). Both sexes were equal (50%). There was no significant difference in Hemoglobin (Hb) (11.08±1.30 g/dL) and random blood glucose (100.65±21.37 mg/dL) (P>0.05) levels. However, there was a significant difference among nationality, type of treatment, patient’s status, and type of WS-RSI compared with non-spine injury (P<0.05). Based on variables, banana boat, foreign travelers, conservative treatment, and outpatient status were having a higher risk in WS-RSI (OR= 4.275; 5.143; 5.014; 7.389; P<0.05, respectively)

Conclusion: As a preliminary study, recent findings at BROS Hospital, Denpasar, Bali suggest that several factors are having a higher risk towards water sport-related spine injuries such as older age, banana boat, foreign travelers, conservative treatment, and outpatient status

The incidence of infection in open cruris fracture grade III A-B treated by external fixation after golden period at Dr. Moewardi General Hospital, Surakarta, Indonesia

Background: The management of open fractures continues to provide challenges for the orthopaedic surgeon. Despite the improvements in technology and surgical techniques, rates of infection and nonunion are still troublesome. Infections in patients with open cruris fracture open after the golden period often occur. There are many risk factors can affect it.

Objective: To determine the incidence rate of infection in patients with open cruris fracture treated by external fixation after the golden period at Dr. Moewardi General Hospital from January to December 2018.

Methods: The characteristics data of patients were observed by retrospective from the medical record of patients that diagnosed open cruris fracture after the golden period from January to December 2018.

Results: In the period of January 2018 to December 2018 there were 55 open cruris fracture with infection incidence rates 72.7% and the most culture result were staphylococcal.

Conclusion: the high incidence rates of infection was found in patients with open cruris fractures; therefore,  it requires treatment as soon as possible before the golden period.

Biological activity of Spondias pinnata: A review

Background: Herbal products are a promising alternative strategy to overcome infection in the era of antibiotic resistance that began to occur. Natural products from plants that are applied in medicine are increasingly and are often used because of the minimal side effects, less toxicity.

Review: Characteristics and plant content of the same species are different depend on ecology and geographic condition of land where the plant is cultivated. “Loloh” is a traditional drink from Bali, one of which is quite well known is loloh cemcem which is often found mainly in the tourist village of Penglipuran Bangli. “Loloh cemcem” is made from “cemcem” leaves or “kedondong” leaves originating from other languages Spondias pinnata. Plants of the genus Spondias, consisting of 18 species, have been used as a traditional medicine to treat various diseases. This plant is widely cultivated commercially in multiple countries to be marketed locally and internationally. The present review highlights the current advances of phytochemical screening, pharmacologic effect, the molecular mechanism of action of Spondias pinnata in health.

Difficulties in the management of Klatskin Tumor: a case report and review of literature

Background:  Tumours of the biliary tract are rare, and difficult to recognize in early stages. Due to its late presentation and the location of the tumour, a definite diagnosis is not always possible pre operatively. Therefore, some guidelines maintained that diagnosing these tumours may be made intraoperatively or post operatively , when tissue samples are available. We report a patient with jaundice and subsequently diagnosed as Klatskin tumour.

Case Description : A 54 years old women came to our surgical clinic with the chief complaint of jaundice for 2 months. MRCP showed mass on the confluent of bile duct, infiltrating both right and left hepatic duct, with no evidence of metastasis or infiltration of portal vein. CEA and CA 19-9 were within normal limits. We found the tumor is clinically did not extend to the bile duct serosa, performed choledocotomy and biopsy of the tumor, requesting frozen section pathology evaluation. The result showed no malignancy. However due to the tumor showed clinical signs of malignancy and caused bile obstruction ,we decided to performed oncological resection of all involved bile ducts and dissection of lymphnodes, and bilateral hepaticojejunostomy bypass Roux en Y. The postoperative pathological evaluation showed an adenocarcinoma.

Conclusion : Difficulties in diagnosing common bile duct malignancy lies in nonspecific clinical symptoms (abdominal discomfort, jaundice, weight loss) and obtaining pathological specimens. The later is due to difficult access to the tumor, while risking injury to adjacent organs. Tumor markers (Ca 19-9 and CEA) are not very sensitive or specific for bile duct malignancy (ranging from 60 to 80%). Positive  results of endoscopic cytology or biopsy range form 30-80%, and are not widely available in our settings. In our cases, when the general patient condition is good, laparotomy, intraoperative biopsy and subsequent resection if possible and neccessary is a possible approach in the management of possible bile duct malignancy. For clinical and radiological highly suspicious Klatskin tumor, exploratory laparotomy, intraoperative biopsy and intraoperative decision based on the findings may be justified. Surgeon must be prepared to perform all necessary procedure before attempting to do laparotomy.