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"Penyakit lambung merupakan penyakit yang paling umum diderita di kalangan masyarakat Indonesia, terutama pada kalangan dewasa. GERD (Gastroephageal reflux disease) merupakan suatu kondisi isi lambung yang naik kembali ke esofagus atau kejadian refluks. Clinical pathway atau alur klinis merupakan suatu rencana terapi dan perawatan multidisiplin berdasarkan praktik klinis. Alur klinis ini dirancang sebagai bentuk usaha terbaik untuk sekelompok pasien dengan diagnosis tertentu, untuk meminimalkan keterlambatan perawatan, memaksimalkan kualitas perawatan serta hasil klinis pada pasien. Panduan praktik klinis di setiap rumah sakit perlu tersedia, khususnya penyakit lambung sebagai penyakit yang paling sering diderita masyarakat Indonesia. Pengerjaan dilakukan dengan studi literatur dan melakukan penelusuran pustaka terkait pengobatan penyakit lambung, terutama golongan obat PPI (proton pump inhibitor), yakni omeprazol, lansoprazol, esomeprazol, pantoprazol, dan rabeprazol. Secara farmakologis, lambung memproduksi asam lambung pada permukaan sel parietal dengan tiga neurotransmiter yang akan terikat ke reseptornya masing-masing. Ketiga neurotransmiter tersebut adalah gastrin dengan reseptor CCK2, asetilkolin dengan reseptor M3 (muskarinik 3), dan histamin dengan reseptor H2. Reseptor CCK2 dan M3 yang teraktivasi akan melepaskan ion K+ melalui jalur Ca2+ dependen. Sedangkan reseptor H2 akan melepaskan ion H+ melalui jalur sikloadenosinfosfat (cAMP) dependen. Kedua ion ini akan tertarik dan mengaktivasi enzim H+/K+-ATPase untuk menukar ion K+ dari lumen dengan H+ ke lumen dari sel parietal. Golongan PPI ini akan menghambat sistem enzim H+/K+-ATPase sehingga ion H+ tidak terproduksi. Oleh karena itu, golongan PPI dapat menghambat sekresi asam lambung.

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Gastric disease is the most common disease among Indonesian people, especially among adults. GERD (Gastroephageal reflux disease) is a condition where gastric contents rise back into the esophagus or reflux occurs. Clinical pathway or clinical flow is a multidisciplinary therapy and care plan based on clinical practice. This clinical pathway is designed as a best practice for a group of patients with a certain diagnosis, to minimize treatment delays, maximize quality of care and clinical outcomes for patients. Clinical practice guidelines in every hospital need to be available, especially gastric disease as the most common disease in Indonesian society. The work was carried out by studying the literature and conducting literature searches related to the treatment of gastric disease, especially the PPI (proton pump inhibitor) class of drugs, namely omeprazole, lansoprazole, esomeprazole, pantoprazole, and rabeprazole. Pharmacologically, the stomach produces gastric acid on the surface of parietal cells with three neurotransmitters that will bind to their respective receptors. The three neurotransmitters are gastrin with CCK2 receptors, acetylcholine with M3 receptors (muscarinic 3), and histamine with H2 receptors. Activated CCK2 and M3 receptors release K+ ions via a Ca2+ dependent pathway. Meanwhile, H2 receptors will release H+ ions via the cycloadenosinfophosphate (cAMP) dependent pathway. These two ions will be attracted and activate the H+/K+-ATPase enzyme to exchange K+ ions from the lumen with H+ into the lumen of the parietal cells. This PPI group will inhibit the H+/K+-ATPase enzyme system so that H+ ions are not produced. Therefore, PPI groups can inhibit gastric acid secretion."

"Penyakit lambung merupakan penyakit yang terjadi di lambung atau bersumber dari lambung. Terdapat beberapa macam penyakit lambung, seperti Gastroesophageal Reflux Disease (GERD), tukak lambung, dan dispepsia. Golongan obat Antagonis Reseptor Histamin H2 atau Antagonis H2, adalah golongan obat penekan asam lambung yang sering digunakan dalam berbagai kondisi penyakit lambung. Clinical pathway atau alur klinis merupakan suatu alat yang digunakan untuk memandu perawatan kesehatan untuk pasien. Pembuatan clinical pathway harus dikembangkan berdasarkan bukti yang tersedia, seperti pedoman praktik klinis yang memuat tatalaksana penyakit, tindakan, dan terapi yang akan diberikan kepada pasien. Peran farmasis dalam clinical pathway adalah dalam manajemen terapi obat, kebutuhan obat pasien, edukasi obat kepada pasien berserta keluarga pasien dan juga tenaga kesehatan, merevisi dan menetapkan protokol pengobatan, dan evaluasi hasil pengobatan. Oleh karena itu, clinical pathway terapi penyakit lambung perlu diketahui untuk memberikan informasi serta rekomendasi terkait pengobatan dan penanganan pasien kepada tenaga kesehatan demi tercapainya hasil pengobatan yang diharapkan dan sebagai manajemen terkait kualitas, biaya, kepuasan pasien dan efisiensi. Metode pelaksanaan tugas khusus ini adalah dengan cara studi literatur untuk pencarian clinical pathway penyakit lambung dengan obat golongan Antagonis H2 dengan mencari sumber atau referensi dan melakukan penelusuran pustaka terkait penatalaksaan atau algoritma penyakit lambung. Berdasarkan hasil studi literatur yang dilakukan, golongan obat Antagonis H2 dapat dijadikan sebagai pilihan terapi untuk GERD ringan, dapat menjadi pilihan untuk mengobati dispepsia tanpa alarm symptoms, baik untuk pasien yang sebelumnya mengonsumsi obat-obatan NSAID ataupun tidak, dan dapat menjadi terapi pilihan untuk penyakit lambung dengan dosis yang berbeda-beda sesuai dengan penyakitnya.

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Gastric disease is a disease that occurs in the stomach or originates from the stomach. There are several kinds of gastric diseases, such as Gastroesophageal Reflux Disease (GERD), peptic ulcers, and dyspepsia. The H2 Histamine Receptor Antagonist drug class or H2 antagonists, is a class of drugs that suppress stomach acid which is often used in various conditions of gastric disease. Clinical pathway is a tool used to guide health care for patients. Making a clinical pathway must be developed based on available evidence, such as clinical practice guidelines that contain disease management, actions, and therapies to be given to patients. The role of pharmacists in clinical pathways is in drug therapy management, patient drug needs, drug education for patients and their families as well as health workers, revising and establishing treatment protocols, and evaluating treatment results. Therefore, it is necessary to know the clinical pathway for gastric disease therapy to provide information and recommendations related to treatment and patient care to health workers in order to achieve the expected treatment results and as management related to quality, cost, patient satisfaction and efficiency. The method of carrying out this special assignment is by means of a literature study to search for clinical pathways for gastric disease with H2 antagonist class drugs by finding sources or references and conducting literature searches related to gastric disease management or algorithms. Based on the results of a literature study conducted, the H2 antagonist drug class can be used as a therapeutic option for mild GERD, can be an option for treating dyspepsia without alarm symptoms, both for patients who have previously taken NSAID drugs or not, and can be the therapy of choice for chronic kidney disease. stomach with different doses according to the disease."

"Latar Belakang: Pasien dengan keganasan gaster berisiko tinggi mengalami malnutrisi. Terapi kuratif utama pada pasien keganasan gaster adalah tindakan operasi, sehingga diperlukan dukungan terapi medik gizi perioperatif yang dapat menunjang perbaikan status gizi, kapasitas fungsional, dan kualitas hidup.Metode: Pasien pada serial kasus adalah dua laki-laki dan dua perempuan, berusia 34-64 tahun, dengan diagnosis tiga pasien dengan karsinoma gaster, dan satu pasien gastrointestinal stromal tumor gaster stadium lanjut. Terapi medik gizi praoperasi diberikan dalam bentuk oral dan parenteral. Pada enam jam sebelum tindakan operasi, dua pasien mendapatkan nutrisi parenteral, dan dua pasien mendapatkan nutrisi oral. Pasien pascaoperasi juga mendapatkan nutrisi enteral dini dalam 48 jam pertama.Hasil: Pasien pasca gastrektomi selama mendapatkan nutrisi perioperatif, tiga pasien mengalami proses penyembuhan luka yang baik, sedangkan satu pasien mengalami komplikasi pascaoperasi berupa fistula enterokutan yang kemudian mengalami pemulihan, dan satu pasien mengalami hiperglikemia dipengaruhi oleh tindakan pankreatektomi distal. Lama masa rawat inap pasien antara 21-31 hari. Semua pasien pascaoperasi mengalami peningkatan kapasitas fungsional.

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Background: Patients with gastric malignancy have high risk of malnutrition. The main curative therapy in patients with gastric malignancies is surgery, so it requires the support of perioperative nutritional therapy which could support the improvement of nutritional status, functional capacity, and quality of life.

Methods: Patients in this case series were two men and two women, aged 34-64 years, and the diagnosis of three patients are advanced gastric carcinoma, and one patient with advanced gastric gastrointestinal stromal tumor. Preoperative nutritional therapy was given in oral and parenteral route. At six hours before surgery, two patients received parenteral nutrition, and two patients received oral nutrition. All patients also got early enteral nutrition in the first 48 hours after surgery.

Results: Patients after gastrectomy during obtaining perioperative nutrition, three patients experienced a good wound healing process, while one patient experienced postoperative complications in the form of enterocutaneous fistula which later recovered, and one patient experienced hyperglycemia that affected by distal pancreatectomy. The length of stay for patients was between 21-31 days, after surgery all patients had increased functional capacity.

Conclusion: Perioperative nutritional therapy in gastric malignancies patients undergoing gastrectomy could help improve the nutritional status and functional capacity."

"Latar belakang: MRCP merupakan teknik pencitraan tidak invasif untuk mengevaluasi anatomi dan mendeteksi kelainan sistem bilier. Cairan di saluran bilier akan memperlihatkan sinyal yang tinggi pada MRCP. Salah satu keterbatasan pemeriksaan MRCP ialah cairan di saluran gastrointestinal juga memberikan sinyal tinggi yang dapat mengganggu evaluasi saluran bilier. Sari buah nanas dapat menjadi kontras oral negatif untuk menurunkan sinyal di gastrointestinal. Belum terdapat penelitian penggunaan sari buah nanas pada pemeriksaan MRCP di Indonesia dan belum terdapat penelitian yang menilai visualisasi cabang-cabang duktus intrahepatikus setelah pemberian sari buah nanas. Tujuan: Mengukur perbedaan SNR gaster dan duodenum serta perubahan tingkat visualisasi cabang-cabang duktus bilier intrahepatikus sesudah pemberian sari buah nanas pada pemeriksaan MRCP. Metode: Dilakukan pemeriksaan MRCP sebelum dan sesudah pemberian sari buah nanas pada subjek penelitian. Mengukur perbedaan rerata SNR gaster dan duodenum serta mengukur perubahan tingkat visualisasi cabang-cabang duktus bilier intrahepatikus sebelum dan sesudah pemberian sari buah nanas. Perbedaan rerata SNR gaster dan duodenum dianalisis menggunakan uji Wilcoxon dan perubahan tingkat visualisasi dianalisis dengan uji McNemar untuk menilai diskordans. Hasil: Didapatkan 25 subjek penelitian yang menjalani pemeriksaan MRCP sebelum dan sesudah pemberian sari buah nanas. Terdapat penurunan bermakna SNR gaster dan duodenum setelah pemberian sari buah nanas, 127,1 (18,7-1194,6) menjadi 42.2 (4,2-377,1) untuk gaster dan 64,1 (3,8-613.4) menjadi 44,6 (6,5-310,3) untuk duodenum (p < 0,05). Terdapat perubahan bermakna tingkat visualisasi duktus bilier intrahepatikus (p < 0,05, diskordans >50%) dengan peningkatan tingkat visualisasi duktus intrahepatikus kanan segmen anterior pada 66% pengamatan, duktus intrahepatikus kanan segmen posterior pada 58% pengamatan, dan 70% pengamatan untuk duktus intrahepatikus kiri. Simpulan: Pemberian sari buah nanas dapat menurunkan sinyal gaster dan duodenum pada pemeriksaan MRCP dan mempengaruhi tingkat visualisasi cabang-cabang duktus bilier intrahepatikus.

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Background: MRCP is a non-invasive imaging technique for evaluating anatomy and detecting abnormalities of the biliary system. Fluid in biliary tract will show high signal on MRCP. One of the limitations of MRCP is high signal in gastrointestinal fluid which can interfere biliary tract evaluation. Pineapple juice as negative oral contrast can reduce signal in gastrointestinal tract. There have been no studies on the use of pineapple juice for MRCP in Indonesia, and no studies assessed the visualization of intrahepatic ductal branches after administration of pineapple juice. Objective: Measuring difference in gastric and duodenal SNR and changes of visualization of intrahepatic biliary ductal branches after administration of pineapple juice on MRCP. Methods: MRCP before and after administration of pineapple juice were performed on subjects. Gastric and duodenal SNR mean difference were measured, and analysis were done with Wilcoxon test. Level of visualization of intrahepatic biliary ductal branches were also measured and analysed with McNemar test for discordances. Results: There were 25 subjects underwent MRCP. Gastric and duodenal SNR were statistically decreased after administration of pineapple juice, 127.1 (18.7-1194.6) vs 42.2 (4.2-377.1) and 64.1 (3.8-613.4) vs 44.6 (6.5-310.3) respectively (p <0.05). Statistically significant difference was observed in visualization of intrahepatic ductal branches (p<0,05), discordance >50%) with increase in visualization of right duct anterior segment in 66% observation, right duct posterior segment in 58% observation, and 70% observation in left intrahepatic bile duct. Conclusion: Use of pineapple juice as negative oral contrast significantly reduce gastric and duodenal signal in MRCP also affect visualization of the intrahepatic biliary duct branches."

"Purpose

The association between the preoperative absolute neutrophil count (NC), lymphocyte count (LC), and monocyte count (MC) in the peripheral blood and the prognosis of gastric cancer (GC) patients has not been investigated widely.

Methods

We enrolled 445 patients who underwent surgery for GC between January, 2005 and April, 2013 to analyze the correlations among NC, LC, and MC and their prognoses.

Results

Based on cut-off values calculated by ROC analysis, patients were sub grouped as having: NC ≥ 4477 (NCHigh), NC < 4477 (NCLow); and as LC ≥ 1447 (LCHigh), LC < 1447 (LCLow); and as MC ≥ 658,5 (MCHigh), MC < 658,5 (MCLow). Each group was assigned as follows; NCHigh group = 1, NCLow group = 0, LCHigh group = 0, LCLow group = 1, MCHigh group = 1, MCLow group = 0, and the sum of each score was defined as the lymphocyte-monocyte-neutrophil score (LMN score). The overall 5-year survival rates were 89%, 74%, 57,8%, and 53,3% for LMN scores of 0, 1, 2, and 3, respectively (P = 0,0004). Multivariate analysis indicated that the LMN score was an independent prognostic indicator.

Conclusions

The combination of preoperative NC, LC, and MC appears to be a useful indicator of GC prognosis."

"Efek samping dari obat golongan proton pump inhibitor (PPI) pada gastrointestinal diantaranya diare dan konstipasi. Tujuan dari penelitian ini adalah untuk mengetahui persentase besarnya efek samping pada gastrointestinal berupa diare dan konstipasi serta melihat adanya hubungan antara efek samping pada gastrointestinal dengan jenis kelamin, usia, dosis PPI, dan lama pemberian PPI pada pasien rawat inap di RSPAD Gatot Soebroto periode Februari ? April 2016. Penelitian ini adalah studi deskriptif analitik. Pengambilan data dilakukan secara prospektif terhadap data sekunder dari resep, dan rekam medis pasien serta data primer melalui wawancara pasien menggunakan kuisioener yang telah diuji validitas dan reliabilitasnya. Pengambilan data dilakukan dari bulan Februari sampai April 2016 secara total sampling. Analisis kausalitas efek samping pada gastrointestinal dilakukan dengan menggunakan algoritma Naranjo. Sampel adalah pasien dengan usia ≥ 17 tahun yang menerima proton pump inhibitor dan bersedia untuk berpartisipasi dalam penelitian ini dengan menandatangani Informed Consent. Pasien yang menjadi sampel dalam penelitian ini sebanyak 58 pasien. Sebanyak 19 pasien (32,75%) mengalami efek samping berupa konstipasi dimana 16 pasien (27,58%) dengan kategori mungkin (probable), dan 3 pasien (5,17%) dengan kategori cukup mungkin (possible). Tidak ada pasien yang mengalami efek samping diare. Hasil analisis statistik dengan uji chi-square dan uji mutlak Fisher menunjukkan tidak ada hubungan antara efek samping pada gastrointestinal dengan jenis kelamin, usia, dosis PPI, dan lama pemberian PPI.

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Prevalances of crohn?s disease and ulcerative colitis in the world are still increasing. These two diseases are categorized as inflammatory bowel disease (IBD). Even there has been some theurapetic option for patient with these diseases, but surgery still the only option to treat fibrotic strictures. Tetrandrine was chosen as drug in this research because of its antifibrotic effect. This research was conducted to develop and evaluate calcium pectinate beads exploiting pH sensitive property for colon-targeted delivery of tetrandrine. Beads were prepared by ionotropic gelation method followed by enteric coating with HPMCP HP-55 or CAP. Uncoated beads were evaluated for particle size, shape, morphology, swellability, process efficiency and encapsulation efficiency. From evaluation, beads with concentration of calcium chloride 5% (formula 1) was chosen as formula for coating. First formula were more spherical in shape, not too sticky, and smaller in size when compared with beads using calcium chloride concentration 10% (formula 2) and 15% (formula 3). Encapsulation efficiency of the three formula, 65.67 ± 0.39%, 68.03 ± 0.12%, 56.28 ± 0.2% respectively. After coating process, beads were used in in vitro drug release and targeted test. The studies showed that coated calcium pectinate beads were sufficient to resist tetrandrine released in acidic medium, but was unsuccessfully in targeting colon."

"Proton pump inhibitor (PPI) is the strongest inhibitor to gastric acid secretion. PPI is effective in all gastric acid disorders, such as: peptic ulcer, gastroesofageal reflux disease, non steroid anti inflammatory drugs (NSAIDs) gastropathy, and zollinger-ellison syndrome. Several studies comparing one PPI to another. Although some differences have been reported, there are small differences with unclear clinical importance. PPI has side effects that may be related to diarrhea due to clostridium difficile, pneumonia, hip fracture, vitamin b12 deficiency, and IgE mediated allergic reaction. Several studies revealed strong association but have limitation in design and sampel size. PPI therapy should be according to indication, dose, and appropriate period."

"ABSTRAKPenyakit ginjal kronik PGK merupakan penyakit kronik progresif yang mengakibatkan penurunan fungsi ginjal dan bersifat irreversible. Pasien PGK stadium akhir membutuhkan terapi pengganti ginjal untuk memertahankan tubuh dari toksisitas uremia. Prosedur dialisis bersifat katabolik, sehingga pasien yang menjalani hemodialisis HD mengalami peningkatan kebutuhan energi dan protein yang penting untuk mencegah terjadinya protein-energy wasting PEW . Empat orang pasien dalam serial kasus ini mengalami PGK stadium akhir dan telah menjalani hemodialisis dengan rentang waktu yang berbeda, 2 orang dalam rawat inap dan dua orang lainnya rawat jalan. Pasien didiagnosis dengan PGK stadium 5 dengan HD, hipertensi, diabetes melitus, dan ensefalopati uremikum. Walaupun saat pemeriksaan status gizi pasien normoweight dan satu orang mengalami malnutrisi ringan, seluruh pasien memiliki riwayat asupan protein 10 dalam 6 bulan, sehingga dibutuhkan terapi medik gizi yang mencakup penentuan kebutuhan makro dan mikronutrien, nutrien spesifik, sesuai dengan toleransi dan kondisi klinis pasien. Hasil pemantauan menunjukkan pasien mengalami perbaikan klinis, toleransi asupan dan kapasitas fungsional serta kualitas hidup pasien dapat dipertahankan. Terapi medik gizi berperan penting pada semua pasien PGK yang menjalani HD dengan mencegah PEW, memperbaiki kondisi klinis, serta meningkatkan kapasitas fungsional pasien.Kata kunci: terapi medik gizi, penyakit ginjal kronik, hemodialisis, hipertensi.

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ABSTRACT

Chronic kidney disease is a irreversible progressive chronic process that causes worsening renal function. Patients with end stage renal disease needs renal replacement therapy to protect themselves from uremia toxicity. Patients who have to undergo dialysis are in high catabolism state and has an increased energy and protein expenditure. Adequate energy and protein for these patients are needed to prevent protein energy wasting PEW . Four cases from this serial case has ESRD and has been on hemodialysis with different time frames. Two outpatient and two inward patients who have CKD stage V with hypertension, diabetes mellitus, and uremic encephalopathy. Although only one patient I categorized as mildly malnourished, 3 of four patients experienced weigth loss 10 in 6 months. Thus, medical nutritional therapy is needed to determine energy and protein requirements in these patients. Evaluation and monitoring form these cases shows that all patients have better clinical outcome, better nutrition intake, and functional capacity were preserved. Medical nutrition therapy has an important role in all CKD patients with dialysis to prevent PEW, to improve their clinical outcome and to increasetheir functional capacity. Key words medical nutrition therapy, chronic kidney disease, hemodialysis, hipertension."

"PPOK merupakan penyakit pernapasan kronis penyebab morbiditas dan mortalitas terbanyak dengan dampak pembiayaan yang cukup tinggi di Indonesia. Clinical Pathway (CP) adalah bagian dari pelaksanaan tata kelola klinis rumah sakit dan salah satu tools dalam mewujudkan sistem kendali mutu dan kendali biaya di era JKN. Efektivitas kepatuhan penerapan clinical pathway (CP) terhadap luaran klinis pasien pada beberapa penelitian menunjukkan hasil yang positif. RS Paru Respira Yogyakarta telah menetapkan CP PPOK sebagai CP prioritas, namun dalam proses evaluasi kepatuhan CP belum menggunakan seluruh komponen PPA seperti yang diatur dalam Permenkes Nomor 30 Tahun 2022. Paradigma pelayanan kesehatan saat ini adalah value-based healthcare sehingga perlu dilakukan evaluasi dampak kepatuhan CP terhadap luaran klinis pasien. Penelitian ini bertujuan untuk mengetahui hubungan kepatuhan CP terhadap luaran klinis pasien PPOK, dan proses penerapan kepatuhan CP PPOK di RS Pusat Paru Respira Yogyakarta tahun 2022. Desain penelitian adalah observasional (cross sectional) dengan pendekatan mix method. Pengambilan data metode kuantitatif menggunakan rekam medis pasien rawat inap dengan diagnosis utama PPOK tahun 2022 (n=57) dan metode kualitatif dengan wawancara mendalam, observasi dan telaah dokumen. Hasil penelitian kuantitatif didapatkan tingkat kepatuhan CP PPOK sebesar 87,7%, ada hubungan yang signifikan antara beban kerja DPJP dengan kejadian komplikasi (p value=0,003) dan antara kepatuhan CP dengan luaran klinis yaitu komplikasi (p value=0,05 dan OR=6,75), faktor yang paling berpengaruh pada luaran klinis pasien adalah kepatuhan terhadap CP. Metode kualitatif, berdasarkan perspektif 10 variabel dalam teori Gibson dan Mathis-Jackson, didapatkan hasil yang baik pada variabel sikap. Untuk variabel pengetahuan, supervisi, komunikasi, pelatihan, SDM, standar kinerja, sarana prasarana, insentif dan struktur organisasi masih perlu peningkatan. Untuk meningkatkan kepatuhan CP diperlukan komunikasi yang efektif antara pembuat dan pelaksana CP, pemahaman dan komitmen penuh para PPA, dukungan manajemen untuk rutin meninjau ulang tata laksana CP, meningkatkan sosialisasi, pelatihan, sarana prasarana, kebutuhan SDM, fasilitas IT penunjang serta regulasi terkait pelaksanaan CP.

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COPD is a chronic respiratory disease that causes the most morbidity and mortality with a high cost impact in Indonesia. Clinical Pathway (CP) is part of the implementation of hospital clinical governance and one of the tools in quality and cost control system in JKN era. The effectiveness of clinical pathway (CP) compliance to patient clinical outcomes in several studies has shown positive results. Respira Pulmonary Hospital Yogyakarta has designated CP COPD as a priority CP, but in the process of evaluating CP compliance, it has not used all Profesional Caregiver components as stipulated in Health Ministerial Regulation No. 30 of 2022. The current paradigm of health services is value-based healthcare, so it is necessary to evaluate the impact of CP compliance on the patient's clinical outcome. This study aims to determine the association of CP compliance to the clinical outcome of COPD patients and the process of implementing COPD CP compliance at the Respira Pulmonary Hospital Yogyakarta in 2022. The research design is observational (cross sectional) with mix method approach. Quantitative method data collection using inpatient medical records with a primary diagnosis of COPD in 2022 (n=57) and qualitative method using with in-depth interviews, observation and document review. The results of quantitative study showed that COPD CP compliance rate is 87.7%, there is a significant relationship between doctor in charge of services workload with the incidence of complications (p value=0.003) and between CP compliance with clinical outcomes of complications (p value=0.05 and OR=6.75), factor that most influenced the patient's clinical outcome was CP compliance. Qualitative methods, based on the perspective of 10 variables in the theory of Gibson and Mathis-Jackson, showed good results on attitude variables. Knowledge, supervision, communication, training, human resources, performance standards, infrastructure, incentives and organizational structure variables still need improvement. To improve CP compliance, an effective communication between CP makers and implementer are required, full understanding and commitment of Profesional Caregivers, management support to regularly review CP governance, improve socialization, training, infrastructure, human resource needs, supporting IT facilities and regulations related to the implementation of CP are required."

"Non-steroid anti-inflammatory drugs (NSAID) can cause gastropathy and gastric mucosa, especially the mucous may play an important prevention role. This cross-sectional, single group study was conducted to evaluated the difference of mucous thickness in antrum or corpus mucosa and the correlation of gastric mucous thickness to gastropathy. Patients who received NSAID from the rheumatology clinic were studied. Healthy subjects of 14 - 65 years old who never received NSAID were included as normal controls. Piroxicam 20 mg daily was given to the patients for 7 days, then gastroscopy and gastric mucosa biopsy with frozen section were performed. Specimens were stained with haematoxyline eosin and thickness of the mucous layer was measured using ocular micrometer. Thirty-two out of 70 patients participated in the study. All cases had hyperemia on gastroscopy with erosions and ulcer in 32 and 9 cases, respectively. The mean thickness of mucosa in distal antrum, proximal antrum and corpus was 28.5 ± 9, 37.4 ± 13.1 and 43.3 ± 13.1 microns, respectively. There was significant relationship between gastric mucosa mucous thickness with gastroscopic findings. In conclusion, this study confirmed that thickness of gastric mucosa mucous has an important role in preventing NSAID gastropathy and dyspeptic complaints in this kind of patients does not suggest abnormalities of gastric mucosa."