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"ABSTRAK Latar Belakang Pada penatalaksanaan fraktur maksilofasial secara internal fiksasi diperlukan pemasangan alat miniplate dan screw sampai terjadi penyembuhan tulang Magnesium memiliki potensi sebagai miniplate dan screw pada tulang rahang dengan syarat bersifat biokompatibel dan biodegradasi sehingga tidak diperlukan operasi kembali untuk pengambilan miniplate dan screw Proses equal channel angular pressing ECAP merupakan salah satu metode untuk mengontrol laju korosi logam magnesium dan meningkatkan sifat mekanisnya Untuk pembuatan desain miniplate dan screw dari magnesium ECAP dengan merujuk dari desain safety factor bahan titanium yang biasanya telah digunakan perlu disesuaikan dengan material properti magnesium agar dapat mencegah kerusakan Tujuan menganalisa perbandingan desain miniplate dan screw logam magnesium ECAP terhadap titanium Metode Untuk penelitian ini kami menggunakan metode finite elemen yaitu formulasi perpindahan untuk menghitung perpindahan komponen strain dan tekanan di bawah beban internal dan eksternal Kemudian desain miniplate dan screw dari magnesium ECAP dilakukan analisa simulasi pembebanan yang dianalisa menggunakan teori Von Misses Hasil Hasil desain miniplate dan screw magnesium ECAP yang diharapkan dapat digunakan pada penatalaksanaan fraktur maksilofasial telah dilakukan simulasi pembebanan dengan dilakukan analisa desain menggunakan teori Von Misses kemudian desain direkayasa untuk mengurangi stress yang diterima desain rekayasa magnesium ECAP dibuat menjadi dua tipe yaitu tipe 1 dengan menambah jumlah screw menjadi 8 screw dengan berat total miniplate dan screw sebesar 118 212 mg dan tipe ke 2 dengan merubah diameter head screw menjadi 2x lebih besar dari bentuk semula sehingga berat totalnya sebesar 169 414 mg Kesimpulan Desain alternatif miniplate dan screw magnesium ECAP tipe 1 dapat lebih efektif untuk digunakan pada penatalaksanaan fraktur maksilofasial ABSTRACT Background In the internal fixation management of maxillofacial fractures the placement of miniplate and screw is necessary until bone repair takes place Magnesium has the potential as a miniplate and screw for the jaws with it rsquo s biocompatibility and biodegradability so that a follow up surgery to remove the miniplate and screw is not necessary The equal channel angular pressing ECAP process is a method to control the corrosion rate of magnesium and increase the mechanical properties In the making of miniplate and screw design from ECAP magnesium referring the safety factor of the titanium design that is already being used adjustments must be made with the characteristics of magnesium so damage can be avoided Objectives to analyze the comparison between magnesium ECAP miniplate and screw design against titanium Methods For this research we used the finite element method which is displacement formulation to calculate component movement strain and pressure under the internal and external load Afterwards the magnesium ECAP miniplate and screw design undergoes a loading simulation which is analyzed with the Von Misses theory Result Design of miniplate and screw magnesium ECAP which expected to be used in the management of maxillofacial fractures has been tested with the stress simulation using Von Misses theory then the design engineered to reduce stress received Engineering design of magnesium ECAP divided into two types type 1 by increasing the number of screw into 8 screws with a total weight miniplate and screws with a total weight miniplate and screw amounted to 118 212 mg and type 2 by changing the diameter of the head screw becomes large than its original shape so that the total weight of 169 414 mg Conclusion Design alternative of miniplate and screw magnesium ECAP type 1could be more effective to be used in the management of maxillofacial fracture ;Background In the internal fixation management of maxillofacial fractures the placement of miniplate and screw is necessary until bone repair takes place Magnesium has the potential as a miniplate and screw for the jaws with it rsquo s biocompatibility and biodegradability so that a follow up surgery to remove the miniplate and screw is not necessary The equal channel angular pressing ECAP process is a method to control the corrosion rate of magnesium and increase the mechanical properties In the making of miniplate and screw design from ECAP magnesium referring the safety factor of the titanium design that is already being used adjustments must be made with the characteristics of magnesium so damage can be avoided Objectives to analyze the comparison between magnesium ECAP miniplate and screw design against titanium Methods For this research we used the finite element method which is displacement formulation to calculate component movement strain and pressure under the internal and external load Afterwards the magnesium ECAP miniplate and screw design undergoes a loading simulation which is analyzed with the Von Misses theory Result Design of miniplate and screw magnesium ECAP which expected to be used in the management of maxillofacial fractures has been tested with the stress simulation using Von Misses theory then the design engineered to reduce stress received Engineering design of magnesium ECAP divided into two types type 1 by increasing the number of screw into 8 screws with a total weight miniplate and screws with a total weight miniplate and screw amounted to 118 212 mg and type 2 by changing the diameter of the head screw becomes large than its original shape so that the total weight of 169 414 mg Conclusion Design alternative of miniplate and screw magnesium ECAP type 1could be more effective to be used in the management of maxillofacial fracture ;Background In the internal fixation management of maxillofacial fractures the placement of miniplate and screw is necessary until bone repair takes place Magnesium has the potential as a miniplate and screw for the jaws with it rsquo s biocompatibility and biodegradability so that a follow up surgery to remove the miniplate and screw is not necessary The equal channel angular pressing ECAP process is a method to control the corrosion rate of magnesium and increase the mechanical properties In the making of miniplate and screw design from ECAP magnesium referring the safety factor of the titanium design that is already being used adjustments must be made with the characteristics of magnesium so damage can be avoided Objectives to analyze the comparison between magnesium ECAP miniplate and screw design against titanium Methods For this research we used the finite element method which is displacement formulation to calculate component movement strain and pressure under the internal and external load Afterwards the magnesium ECAP miniplate and screw design undergoes a loading simulation which is analyzed with the Von Misses theory Result Design of miniplate and screw magnesium ECAP which expected to be used in the management of maxillofacial fractures has been tested with the stress simulation using Von Misses theory then the design engineered to reduce stress received Engineering design of magnesium ECAP divided into two types type 1 by increasing the number of screw into 8 screws with a total weight miniplate and screws with a total weight miniplate and screw amounted to 118 212 mg and type 2 by changing the diameter of the head screw becomes large than its original shape so that the total weight of 169 414 mg Conclusion Design alternative of miniplate and screw magnesium ECAP type 1could be more effective to be used in the management of maxillofacial fracture "

"Pendahuluan: Masalah fungsional dan kosmetik semakin meningkat akibat adanya defek pada area craniofacial termasuk mandibula yang membentuk bagian bawah wajah. Rekonstruksi mandibula bertujuan memberikan kemungkinan maksimal dari hasil fungsional dan estetik. Hasil yang optimal dari fungsi rekonstruksi mandibula adalah salah satu tujuan dari penggunaan teknik flap bebas fibula. Dengan bantuan dari perkembangan system proses komputer dalam desain dan pembuatan, operasi craniomaxillofacial dapat dilakukan dengan bantuan komputer melalui berbagai bentuk dan variasi tujuan. Dalam rangka menelaah kualitas dari penelitian yang telah tersedia dan memberikan informasi untuk pengambilan keputusan, kajian mengenai perbadingan operasi dengan bantuan komputer (CAS) dengan metode konvensional freehand (CFS) menjadi penting untuk dilakukan. Metode: Pencarian pustaka sistematis dilakukan pada pusat data PubMed, ProQuest, Cochrane Library, EBSCOhost, Wiley Library, Science Direct, dan Scopus, mencakup semua studi dengan data utama yang membandingkan hasil akurasi, efisiensi, komplikasi, dan fungsional diantara kelompok CAS dan CFS. Risiko bias studi dinilai menggunakan Newcastle-Ottawa Scale (NOS). Meta-analisis dilakukan melalui Review Manager. Hasil: Enam belas studi kohort memenuhi kriteria eligibilitas dari 355 studi pada pencarian awal. Studi dengan hasil yang sama (akurasi, efisiensi, komplikasi, dan fungsional) dibandingkan antara kelompok CAS dan CFS. Sebanyak 13 studi menunjukkan hasil signifikan secara statistik pada penilaian efisiensi: waktu ischemia lebih singkat (-34.84 menit, 95% CI: -40.04 to -29.63; p<0.00001; I2=94%), total waktu operasi lebih singkat (-70.04 menit, 95% CI: -84.59 to -55.49; p<0.00001; I2=77%), waktu rekonstruksi lebih singkat (-41.86 minutes, 95% CI: -67.15 to -16.56; p=0.001; I2=93%), dan lama rawat inap yang lebih singkat(-2.98 days, 95% CI: -4.35 to -1.61; p=0.0001; I2=7%) pada kelompok CAS dibanding kelompok CFS. Kesimpulan: Kajian sistematis dan meta-analysis menunjukkan hasil yang lebih baik pada kelompok CAS dibandingkan dengan CFS yang signifikan pada hasil efisiensi, Namun beberapa studi melaporkan berbagai analisis statistik dengan berbagai parameter untuk kategori hasil komplikasi, akurasi, dan fungsional. Seluruh studi sepakat bahwa CAS memberikan manfaat yang lebih dibandingkan CFS, walaupun CFS masih dapat menjadi pilihan.

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Background: Major functional and cosmetic problems will arise from defects in craniofacial regions, including mandible which constructs the shape of lower third of the face. The aim of mandibular reconstruction is to achieve the best possible functional and aesthetic outcomes. The optimal return of mandibular bone function is one of the reconstruction goals using free fibular flap (FFF). With aid of the evolving computer processing system for design and manufacturing, craniomaxillofacial surgery can be conducted with computer-aided surgery in many forms and varied proposes. In order to evaluate the quality of available article and to provide information for decision-making, review of comparison between computer-aided surgery (CAS) and conventional freehand surgery (CFS) need to be evaluated.

Methods: A systematic search was conducted on PubMed, ProQuest, Cochrane Library, EBSCOhost, Wiley Library, Science Direct, and Scopus, including all studies with primary data that compared accuracy, efficiency, complication, and functional outcomes between CAS and CFS group. Risk of bias for included studies were assessed based on Newcastle-Ottawa Scale. Meta-analysis was performed in Review Manager.

Results: Sixteen cohort studies were included that meet the eligibility criteria from initial searches of 355 studies. Studies with the same outcome (accuracy, efficiency, complication, and functional) are compared in CAS and CFS group. Thirteen studies demonstrated statistically significant efficiency outcomes: shorter ischemia time (-34.84 minutes, 95% CI: -40.04 to -29.63; p<0.00001; I2=94%), shorter total operative time (-70.04 minutes, 95% CI: -84.59 to -55.49; p<0.00001; I2=77%), shorter reconstruction time (-41.86 minutes, 95% CI: -67.15 to -16.56; p=0.001; I2=93%), and shorter length of hospital stay (-2.98 days, 95% CI: -4.35 to -1.61; p=0.0001; I2=7%) in CAS group than CFS group.

Conclusion: Systematic review and meta-analysis demonstrated higher outcomes CAS group compared to conventional group significantly in efficiency outcomes. However, some studies performed diverse statistical analysis on several parameters for outcomes category such as complications, accuracy, and functional. All studies agreed that CAS group has higher benefits than conventional method, although the conventional method is still an option."

"Latar Belakang. Terapi baku emas dalam penutupan defek septum ventrikel (DSV) adalah pembedahan. Prosedur pembedahan mempunyai morbiditas yang terkait dengan torakotomi, pintasan jantung paru, komplikasi prosedur, jaringan parut bekas operasi, dan trauma psikologis. Oleh karena itu, timbul usaha pendekatan transkateter untuk menutup DSV yang bersifat relatif kurang invasif. Tujuan. Mengetahui perbandingan hasil penutupan DSV perimembran, komplikasi prosedur, lama rawat di rumah sakit, dan total biaya prosedur antara prosedur transkateter dengan prosedur pembedahan. Metode. Penelitian retrospektif analitik dengan data berupa rekam medis pasien anak dengan DSV perimembran yang datang ke Pelayanan Jantung Terpadu Rumah Sakit dr. Cipto Mangunkusumo dan dilakukan penutupan defek dengan salah satu prosedur dalam periode Januari 2010-Desember 2013. Hasil. Sebanyak 69 kasus anak dengan DSV perimembran masuk dalam penelitian, terdiri dari 39 kasus dengan prosedur pembedahan dan 30 kasus dengan prosedur transkateter. Prosedur pembedahan dan prosedur transkateter mempunyai tingkat keberhasilan yang serupa (89,7% vs 96,7%, p=0,271). Prosedur pembedahan mempunyai komplikasi yang lebih banyak dibandingkan prosedur transkateter (46,7% vs 7,7%, p < 0,001). Prosedur pembedahan juga mempunyai lama rawat di rumah sakit yang lebih panjang dibandingkan prosedur transkateter (8 hari vs 3 hari, p<0,0001), dan semua prosedur pembedahan membutuhkan perawatan di ruang rawat intensif. Tidak ada perbedaan total biaya antara prosedur transkateter dengan prosedur pembedahan (Rp. 55.032.636 vs Rp. 58.593.320 p = 0,923). Simpulan. Prosedur penutupan DSV perimembran secara transkateter mempunyai efektivitas dan biaya yang sama dengan prosedur pembedahan dan mempunyai komplikasi yang lebih sedikit serta lama rawat di rumah sakit yang lebih pendek.

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Background. Surgery has become standard therapy for ventricular septal defect (VSD) closure, but it has significant morbidity related to sternotomy, cardiopulmonary bypass, complication, residual scar, and trauma. Non-surgical and less invasive approaches with transcatheter device were developed to occlude VSD.

Objectives. To compare efficacy, complication, length of hospital stay, and total cost of perimembran VSD closure procedure between transcatheter closure and surgery.

Methods. A retrospective analysis was performed on children with perimembran VSD admitted to Cardiology Center of Cipto Mangunkusumo Hospital from January 2010-December 2031. The patients received transcatheter closure or surgical closure. Data were obtained from medical record.

Results. A total of 69 perimembran VSD cases were included in study, consisted of 39 cases underwent transcatheter closure and 30 cases underwent surgical closure. The efficacy of both procedur were not statistically different (89.7% vs 96.7%, p=0.271). However, surgery procedure had more complication than transcatheter closure (46.7% vs 7.7%, p < 0.001). Hospital stay were also significantly longer for surgery procedure than transcatheter closure (8 days vs 3 days, p<0.0001), and all surgical subjects requiring intensive care. Transcatheter closure had median total cost Rp. 55.032.636 as compared with Rp. 58.593.320 for surgery procedure (p =0.923).

Conclusion. Perimembran VSD transcatheter closure had similar efficacy and costs with surgical closure. Complication rate was lower, and the length of hospital stay was shorter."

"Pembatalan operasi elektif di RSUP Dokter Kariadi, sebesar 6,49% di atas angka standar tahun 2012 ( ≤ 5% ). Pembatalan operasi elektif dapat menyebabkan ketidakpuasan pasien, peningkatan biaya, lama rawat pasien di rumah sakit, dan mencerminkan inefisiensi. Penelitian ini bertujuan untuk mengetahui faktor-faktor yang berhubungan dengan pembatalan operasi elektif. Sebanyak 6,8 % operasi elektif dibatalkan karena alasan medis 106 (46,1%) dan non medis 124 (53,9%). Pembatalan operasi berhubungan dengan kondisi pasien, hasil laboratorium tidak normal, dan kesiapan operator. Sehingga disarankan untuk dikembangkan klinik pra bedah.

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Cancellation of elective surgery at Doctors Hospital Kariadi, amounting to 6.49% is still above the standard ( ≤ 5% ). Cancellation of elective surgery could lead to patient dissatisfaction, increased costs, length of stay and reflects the inefficiency. This study aims to determine the factors associated with the cancellation of elective surgery. 6.8 % elective operations were canceled due to medical reasons (46.1%) and non-medical (53.9%). Cancellation of operations related to the patient's condition, abnormal laboratory results, and operator. It is suggested to develop pre ? surgery clinic."

"Penelitian ini bertujuan mengetahui faktor-faktor yang berhubungan dengan keterlambatan operasi elektif di kamar bedah RS Awal Bros Pekanbaru. Variabel yang diteliti adalah kedatangan tim operasi, kedatangan pasien, waktu persiapan pasien, operasi cito sebelumnya,keterlambatan operasi sebelumnya, kelengkapan sarana operasi, kelengkapan administrasi dan kondisi medis pasien.Penelitian ini adalah penelitian gabungan kuantitatif dan kualitatif, menggunakan data retrospektif dengan desain penelitian cross sectional dilanjutkan dengan metode concensus decision making grup CDMG. Sampel dalam penelitian ini menggunakan penghitungan rumus penelitian Slovin, dengan jumlah sampel 100 sampel. Pengumpulan data menggunakan instrumen penelitian dan data sekunder dari laporan kinerja kamar bedah. Uji statistik yang digunakan dalam penelitian ini adalah analisis univariat dan analisis bivariat menggunakan uji chi square.Hasil penelitian pada uji statistic bivariat, dari semua variabel yang diteliti ada 3 yang memiliki hubungan signifikan dengan keterlambatan operasi elektif,yaitu kedatangan pasien, waktu persiapan pasien, dan keterlambatan operasi sebelumnya. Kesimpulan pada penelitian ini didapatkan bahwa angka keterlambatan operasi elektif adalah 81,15 menit jauh diatas standar mutu RS yang ditetapkan yaitu

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This study aims to determine the factors associated with the delay in elective surgery in the operating room of Awal Bros Pekanbaru Hospital. The variables studied were the arrival of the surgical team, the arrival of the patient, the patient 39 s preparation time, the previous citosurgery, the previous surgical delay, the completeness of the surgical means, the administrative completeness and the patient 39 s medical condition.

This research is a quantitative and qualitative combined research, using retrospective data with cross sectional research design followed by concensus decision making grup CDMG. The sample in this study used Slovin formula calculation, with sample size of 100 samples. Data collection using research instruments and secondary data from surgical room performance reports. The statistical test used in this research is univariate and bivariate analysis using chi square test.

Result of the research on bivariate statistic test, from all variables studied there are 3 which have significant relation with elective surgery delay, that is patient arrival, patient preparation time, and previous operational delay. The conclusion of this research is that the elective operation delay is 81.15 minutes far above the defined standard of hospital quality."

"

Latar belakang: Bovine jugular vein (BJV) conduit telah menggantikan fungsi homograft untuk prosedur operasi rekonstruksi right ventricle outflow tract (RVOT). Penelitan ini bertujuan melihat kesintasan jangka panjang pasien yang dilakukan rekonstruksi RVOT menggunakan BJV conduit. Metode: Total 58 BJV conduit yang dimplantasi di satu pusat jantung pada tahun 2010 hingga 2016. Karakteristik pasien serta evaluasi ekokardiografi didapatkan dari rekam medis. Peneliti melakukan analisa kesintasan terhadap luaran kardiovaskular yang terjadi. Luaran kardiovaskular berupa stenosis, regurgitasi, endokarditis serta operasi ulang. Hasil: Kesintasan selama tujuh tahun, pasien usia dibawah 24 bulan dan diatas 24 bulan terhadap luaran kardiovaskular sebesar 74,1% dan 87,1%. Usia subjek dibawah 24 bulan meningkatkan risiko terjadinya luaran kardiovaskular sebesar 1,18 kali. Kesintasan selama tujuh tahun terhadap luaran kardiovaskular untuk BJV conduit ukuran 12-14 mm dan 16-22 mm adalah 77%, dan 87%. Penggunaan ukuran 12-14 mm BJV conduit, meningkatkan kejadian luaran kardiovaskular sebanyak 1,13 kali. Kesimpulan: Usia dibawah 24 bulan dan penggunaan ukuran BJV conduit 12-14 mm yang meningkatkan risiko terjadinya luaran kardiovaskular, maka perlu dipertimbangkan operasi paliatif pada pasien agar dapat menggunakan BJV conduit yang lebih besar dikemudian hari.

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Backgrounds: Bovine jugular Vein (BJV) conduit have replaced homograft function for right ventricle outflow tract (RVOT) reconstruction. This study purpose was to study long-term survival patient who undergo RVOT reconstruction with BJV conduit. Method: A total of 58 BJV conduit implanted in one heart center in 2010 until 2016. We gathered subject characteristic and echocardiography findings from medical record. We performed survival analysis based on cardiovascular events as the outcome which were stenosis, regurgitation, infective endocarditis, and re-operation. Result: The seven-year cardiovascular events were: patients less than 24 mo (74,1%), more than 24 mo (87,1%), BJV 12-14 mm in diameter (77%), 16-22 mm (87%). Age less than 24 mo and BJV conduit 12-14 mm in diameter increase risk of cardiovascular events 1,18 times and 1,13 times. Conclusion: Age less than 24 mo and BJV conduit 12-14 mm in diameter increasing risk of cardiovascular events. Thus, palliative surgery needs to be considered, allowing the use of conduit with a larger diameter. 

"

"Komite Medik RSU Karawang yang baru berusia satu tahun merupakan wadah non struktural yang melaksanakan tugas dan fungsinya sebagai pengendali kualitas pelayanan di rumah sakit, masih menghadapi berbagai kendala-kendala yang belum dapat terpecahkan. Dengan struktur ketenagaan, pembiayaan dan piranti lunak dari pimpinan rumah sakit, proses Komite Medik dapat berjalan, namun masih belum optimal, sehingga dampaknya tehadap outcome tindakan bedah, terutama terhadap kualitas pelayanan medik, belum terlihat. Masalah ini diakibatkan karena struktur yang mendukung, belum mecakup dukungan stuktural berupa sarana gedung dan peralatan yang memadai. Disamping itu prosedur tetap tentang kegiatan-kegiatan komite medik masih belum lengkap, sehinga proses belum dapat berjalan dengan optimal. Kaitannya dengan outcome tindakan bedah, oleh karena berdasarkan pengalaman di negara Amerika (Phartenon, 1979) 75% tuntutanmasyarakat pengguna yang diajukan terhadap dokter, 82% diantaranya ditujukan kepada para dokter yang melakukan tindakan pebedahan.Oleh Karena itu, diperlukan peningkatan peran manajemen rumah sakit, untuk turut serta mengupayakan pemecahan masalah yang dihadapi oleh komite medik dan untuk mencegah terjadinya tuntutan masyarakat pengguna, dengan cara perbaikan struktur dan proses komite medik yang pada akhirnya akan berdampak terhadap meningkatnya kualitas pelayanan (outcome).Penelitian ini bersifat studi kasus dengan pendekatan kualitatif, karena meneliti struktur proses dan outcome yang sudah memiliki pola. Fokus penelitian adalah komite medik, yang berkaitan dengan struktur, proses kegiatan komite medik, serta outcome dari tindakan bedah di RSU Karawang.Dari hasil penelitian, didapat suatu gambaran bahwa pengorganisasian komite medik berdampak positif terhadap struktur, proses dan outcome tindakan bedah, sehingga hasil penelitian ini dapat digunakan untuk membentuk suatu konsep pengembangan komite medik di Rumah Sakit Umum Daerah Unit Swadana Daerah kelas C Kabupaten Daerah Tingkat II Karawang. Konsep ini dibentuk berdasarkan tinjuan pustaka dan penelitian langsung di lapangan.Hasil ini merupakan masukan kepada manajemen rumah sakit, sebagai dasar dalam pengembangan Komite Medik.Daftar Pustka: 32 (1972 - 1995).

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Medical Staff Organization (MSO) is a functional unit in Karawang Hospital , with an objective to monitor and control the quality of medical services. This unit has been working since 1995, and still have a lot of problems in organizing is activities. This study is intended to compare structure, process and outcome of medical staff activities in Karawang Hospital, during the period of pre-MSO (1994) and post MSO (1995).The trigger initiating MSO activities in Karawang Hospital is the Director's decree (SK) on development of MSO in Karawang Hospital. The new MSO organization has a full support from the Hospital Director with facilities, financial supports and methods.MSO activities in 1995 was increasing very fast, with 36 MSO meeting where almost 80% of all the doctors present. Mortality evaluation meetings, morbidity meetings, nosocomial task force, statistical evaluation of quality of medical services, completeness of medical records suddenly become a medical concern in the hospital. MSO budget for meetings and training of medical staff jumped from 1,6 millions rupiah in 1994 to 7,7 millions in 1995 and projected to 50 millions in 1996. Result of the study shown that MSO was very active in 1995 compared to the situation in 1994.Outcome of MSO in this study is measured by the quality of medical surgeries conducted in 1994 and 1995. The study shown the decrease in waiting time for surgery, and length of stay after surgery in 1995 compared to 1994. Since mortality rate is influenced by the condition of patients when they came to the hospital, the outcome data should look further to the increasing rate of infection after surgeries. The study suggest to look at nosocomial infection, quality of nursing of patients facilities, and improvement of quality of medical services through the development of standard operating procedures for every surgeries in Karawang Hospital.The study concluded that MSO had a positive impact on the quality of medical surgeries in Karawang Hospital. One of the important finding of this study is that MSO will not working properly without a full support and attention of Hospital Director.Reeferences : 32 (1972 - 1995)."